Practical Aspects of Insulin Pumping

1
(No Transcript)
2
Practical Aspects of Insulin Pumping

• DeAnn Johnson, RN, BSN, CDE
• Susie Owen, RN, CDE

3
Overview

• Evidence for pump therapy
• Patient selection
• Dosing
• Set and site issues
• Pump attire
• Sick Days
• Travel
• Case study
• Discussion

4
BDC results1 year pre CSI compared to ea yr
thereafter
Chase HP et al, Diabetes Technology
Therapeutics, 9421,2007
5
Severe Hypoglycemia and Insulin Pumps (CSII)

Maniatis, Chase, et al.
Pediatri,107,351 2001
Scrimgeour, Chase, et al D T T
9421, 2007
(In DCCT 62per 100 pt. yrs NEJM, 329, 977,
1993)
6
Whos a good candidate?
7
Essential Criteria for Pump InitiationSurvey of
54 Diabetes Educators
All 54 respondents ranked SMBG as an
essential criteria for pump start
Lenhard et. al., Infusystems USA 3, 1, 2006
8
2007 Consensus Statement on Pump Use in Peds-
Patient SelectionEndorsed by the ADA European
Assoc. for the Study of Diabetes

• Recurrent severe hypoglycemia
• Wide fluctuations in bg levels regardless of A1c
• Suboptimal diabetes control
• Micro/macro vascular complications
• Good control but regimen compromises lifestyle
• Infants and neonates
• Adolescents with eating disorders
• Children and adolescents with pronounced dawn
  phenomenon
• Pregnant adolescents
• Ketosis-prone individuals
• Competitive athletes
• Children with needle phobia

Battelino,P.M., Rodriguez,H.D., Kauffman, F. Use
of insulin pump therapy in the pediatric
age-group consensus statement from the European
Society for Paediatric Endocrinology, the Lawson
Wilkins Society and the International Society for
Pediatric and Adolescent Diabetes, endorsed by
the American Diabetes Association and the
European Association for the study of Diabetes
Care Diabetes Care 200730, 1653-1662
Blackett PR Insulin Pump Treatment for
Recurrent Ketoacidosis in Adolescence Diabetes
Care199518891-892. Maniatis AK et al,
Pediatric Diabetes 2001 June2(2)51-57.
9
Basal Dosing

• Half total daily dose. May decrease by 10-30.
  Divide over 24 hours
• Convert Lantus or Levemir dose directly into
  basal
• Set pump up in 3 hour increments
• Consider dilution to U50 (off label) if using
  lt.05 u/Hr.
• To order diluent for Humalog 1-800-821-0538,
  for Novolog 1-800-727-6500
• Keep timing of basal dosing in mind for
  disconnections
• Use alternate increased basals for menses,
  illness, steroid use and alternate lower basals
  for high exercise days/nights

10
Basal Dosing Needs
B and C 708 and 83 primarily pubertal subjects D
152 subjects F 117 pre-pubertal subjects
From Holterhus PM, et al., Diabetes Care, 2007
30(3)568-73.
11
Bolus Dosing

• Consider using Rule of 500 (carbs) Rule of
  1700 (correction)
• Bolus 15-30 minutes prior to meal

12
Dual Wave Bolusing
Mean change in blood glucose levels following
four methods of bolus administration. (Chase HP
et al. Diab Med 19317, 2002.)  
13
Use of the Combination or Dual

• Useful for all high fat/ high carb meals
• May add a unit to total bolus to combat decreased
  insulin sensitivity
• Starting point Take ½ (50) of bolus immediately
  and extend the other half (50) over the next 2
  hours
• Check bg at 2,4 and 6 hours
• Make adjustments as needed (examples)
• gt 180 at 2 hrs. ? to 60 Immediate bolus
• lt 70 at 2 hrs. ? to 40 Immediate bolus
• gt 180 at 4 hrs. ? to 60 Extended bolus

180mg/dl 10mmol/L
14
Forgotten Boluses Increase of a half point in
A1c if just 2 boluses missed per week!

• Use of pump alarms
• Cell phone alarm
• Food in mouth, hand on pump!
• Upside down plate
• Bolus for all carbs (except tx of lows)
• Parental review
• Evaluate for eating disorder

Chase HP, et al Pediatrics 113,221,2004
15
Exercise

• Jason Johnson, a pitcher for the Detroit Tigers
  was diagnosed with Type 1 Diabetes when he was
  11.
• The MLB approved use of insulin pumps during
  games in 2004.

16
Exercise Dosing

• Disconnect for duration. Test every 2 hours
  minimum. May need 50 bolus pre-disconnection
  for anticipated missed basal correction and
  additional corrections throughout activity.
• 25-75 decreased temp basal during moderate to
  intense extended duration activity. May start up
  to an hour prior.
• 25-75 reduction to alternate basal for delayed
  hypoglycemia during the night starting 2 hours
  prior to expected drop.
• Potential 25-75 decrease to bolus just prior to
  activity and/or immediately following.

17
Choosing the Right Site and Set
18
Site and Set Considerations

• Pinch test
• Hypertrophy/lipo-atrophy
• Curves
• Disconnection access
• Diapers
• Activities

19
90 Degree Infusion Sets
Cleo
Quick set
Inset
Rapid D
Sure T
20
Angled Infusion sets
Inset 30
Comfort Silhouette Tender
Omnipod
21
(No Transcript)
22
Minimize Pain and Anxiety

• Desensitizationbreathing/ distraction/
  visualization bubbles, I Pod
• Use of inserter
• Use of buttock/hip
• Parent wears at saline start
• Respect rituals

Maniatis AK et al, Pediatric Diabetes 2001
June2(2)51-57.
23
Numbing agents

• ice teething rings, cold stones
• Gigi Waxing Spray
• L-M-X4
• Emla crème, generic lidocaine 2.5 /prilocaine
  2.5 crème (discs or use with wax paper)

24
Where to wear?

• alana-mireilleapparel.com
• Kangaroo Pump Pockets
• Mypumpgear.com
• Pumpwearinc.com
• store.minimed.com

25
Wearing the Pump
26
Cell Phone/PDA Holders as Pump/PDM Holders
27
Making it Stick (or not)

• Antiperspirant
• Skin Prep, IV Prep, Bard wipes
• Skin Tac / Tac Away
• Mastisol / Detachol
• IV3000,Tegaderm Polyskin, Water proof sports tape
• STR Surgical and Sports Tape Remover

28
Sick Days

• Test blood or urine ketones if gt300 or gt240 twice
• Give a shot and change set if positive
• Increase fluid intake
• Use of temp basal
• Extra tape to site for surgery

29
Vacations

• 10-50 reduction in dosages
• Travel letter and current dosing
• Take along loaner pump and/or basal insulin
  syringes
• More frequent set changes