INSULIN%20INFUSION%20PUMP

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INSULIN INFUSION PUMP

• Seminar by
• Vemula Praveen Kumar
• M.pharmacy II semester
• (Pharmaceutics)
• University College of Pharmaceutical Sciences,
  
• Kakatiya University,
• Warangal.

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CONTENTS

• Introduction to insulin infusion pumps (pump)
• How to choose a pump and infusion set
• Working of pump
• Use of pump
• Formulas that help
• Site site supplies
• Advantages disadvantages with pumps
• Problems with pump site
• Helpful habits attributes
• Conclusion
• References

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About insulin

• Insulin is a hormone, normally produced by
  pancreas
• Low levels of insulin (basal insulin) are
  required to block the uncontrolled breakdown of
  fats and glycogen into energy substrates for the
  body
• High levels of insulin(bolus insulin) stimulate
  the storage of sugar in muscle and fat.

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Insulin Infusion Pump

• Insulin infusion Pump (IIP) is an external
  battery-powered device that delivers insulin at
  regularly scheduled intervals, day and night
  (through a short, flexible plastic tube inserted
  just under the skin), into the body at a
  programmed rate to control blood sugars

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Insulin release pattern
R/Lispro/Aspart
Endogenous insulin
Three Injection Regimen
Insulin Effect
Ultralente
D
B
L
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Insulin release pattern
Endogenous insulin
CSII or IIP
Insulin Effect
D
B
L
Continuous delivery through the IIP, more closely
mimics the natural secretion of insulin from the
pancreas.
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Insulin Infusion Pumps

• Fairly recent technology.
• Generally fairly easy to use.
• Requires close patient involvement.
• More thinking and monitoring than insulin by
  syringe.
• 3,00,000 users worldwide.
• Operation is very simple, because the interface
  is similar to a cell phone keypad.

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Where Pumps Began

• Started 1978 with conversion of portable
  chemotherapy pumps to delivery of insulin
• The Auto syringe AS2C and Harvard Apparatus Mill
  Hill Infuser were first
• Single basal, no memory
• 50 ml syringe on pump exterior

1978 Autosyringe AS2C gt
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1977Blood Glucose Meter
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Block Diagram of IIP
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When To Consider A Pump

• More than 3 injections per day
• Tired of multiple injections
• Frequent or severe hypoglycemia
• Hypoglycemia unawareness
• DKA hospital admission
• Require small, precise doses
• Less risk of complications

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Terms

• Basal Rate that which is flowing between meals
  or boluses
• Bolus sudden increase such as to adjust for a
  meal or abnormal sugar
• Suspend to stop the basal rate for some time
• Infusion set the cannula and tubing that goes
  from pump to skin and SQ tissue

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Types of Pump

• Open loop User gathers sugar data and adjusts
  flow rates for activity, diet, other changes in
  sugar
• Closed loop The device checks sugar and adjusts
  insulin infusion
• Pumps use short acting insulin
• Disappears faster
• Acts faster, so adjustments made faster

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First Steps Toward A Pump

• Keep detailed records
• Consider your (and your childs) motivation
• Acceptance issues, family support
• Look at available pumps
• Which pump(s) does your insurance cover?
• How your pump works
• When to increase and decrease basals and boluses
• How to adjust for high GI foods, extra activity

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Things To Consider while selecting a
pump

• Look, feel, color
• Features reminders, child block, waterproofing
• Size of basal and bolus increments
• Infusion set choices
• Safety
• Customer support
• History
• Ease of data analysis
• Add-ons meters, covers

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Pump Companies

• Animas R1200
• Dana Diabecare III
• Deltec Cozmo
• Medtronic Paradigm
• Nipro Amigo
• Roche/Disetronic

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Working of IIP

• The pump is programmed to deliver a constant
  background rate of insulin called a basal rate,
  which may change at various times during the day,
  to closely match the individuals needs.
• Typically, the basal rate does not need to be
  changed often, once the persons blood glucose
  patterns are known.
• There may be some variation due to changing sleep
  / wake schedules or monthly hormonal changes.
• These changes can be accommodated quite easily
  with the pump and therefore achieve better blood
  sugar control than insulin injections

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Working of IIP

• A lead screw and nut (describes as a drive rod)
  that would compress the syringe to inject the
  insulin.
• The lead screw pushes down on the drive rod,
  which is actually a complex machined plastic
  plunger.
• The precision fit of the lead screw and nut not
  only ensures the proper performance of the pump,
  it creates sealing features that help maintain a
  strict separation between the medication and the
  pump parts.

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Before IIP Using

• Everyone is nervous
• Read, read, read
• Pumping Insulin, Kids Insulin Pumps And You
  (Animas), and information booklets, visit
  websites
• www.myomnipod.com
• www.minimed.com etc, etc ...
• Do lots of recording before and after start
• Start to play with pump as soon as it arrives
• Get telephone contacts MD, CDE, pump company,
  pump rep.

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IIP sites Site Preparation

• Prevents pump bumps, infection, and abscess
• Steps
• Wash the hands
• Sterilize the skin IV Prep
• Use bio-occlusive adhesive IV 3000
• Insert the set
• Use safety tape

IIP sites
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Site Supplies

• Emla cream (Rx, 30 min wait) or ice cube
• Set inserter ezSerter, Quick-Serter, Sil-Serter,
  Sof-Serter
• Adhesive IV-3000, Hypafix, Tegaderm
• Tape Micropore, Durapore, Band-Aid Blister
  Relief (wicking)
• Sweating aid Mastisol Spray (Detachol for
  removal), Skin Tac, Tincture of Benzoin, Skin
  Prep
• Adhesive removal Uni-Solve, Allkare

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Use of IIP

• The tube and needle are referred to as an
  infusion set.
• Infusion sets
• Straight-In Teflon Cleo, Inset, Ultra flex,
  Quik-Set
• Easier to insert at variety of depths (6, 8, 9
  mm)
• Angled Teflon (Comfort, Tender, Easy)
• Longer is more secure
• Adjust angle to reach fat
• Metal needles (Rapid-D or bent needle)
• As comfortable and often more reliable
• Very short, multi-needle infusion sets expected
  soon

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Infusion Sets And Inserters
Disetronic Rapid-D
Smiths Medical Cleo
Animas Inset
Quik-serter
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Crab counting

• Carbohydrate counting is an effective way to
  control insulin regimens by means of giving only
  enough insulin to cover the grams of carbohydrate
  ingested. With an insulin pump, you simply add up
  your carbohydrates ingested, and insert the
  number into the pumpjust like a calculator.
• The pump then figures out, based on your
  programmed ratio, how much insulin is needed to
  cover your carbohydrates
• Allows precise matching of carbs with boluses
• Glycemic index, saturated fat, and high protein
  all play a role, but grams of carb is what
  controls the blood sugar after a meal
• Easy!

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Carb Counting

• How To Count Carbs
• Food labels
• Check portion size
• Books
• Drs Pocket Guide, Health Cheques
• Keeps blood sugar normal after meals

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• The formula for calculating a correction dose is
  as follows
• 1. Add the total daily dose (include both basal
  and bolus amounts) and then divide 1,800 by that
  number. The result is the decrease in glucose
  (mg/dl) one would achieve with 1 unit of insulin
  as a correction dose.
• 1,800/Total Insulin Dose Decrease in Glucose
  (mg/dl) per 1 unit of insulin (This is the
  insulin sensitivity factor.)
• 2. Calculate the number of units of insulin
  needed based on the current glucose level and
  planned carbohydrate intake. Patients should test
  their glucose levels 23 hours after delivering
  the bolus to assess the outcome.
• Example J.D. normally takes 30 units of insulin
  per day 15 units as basal and
• 15 units as bolus (5 units with each meal)
• 1,800/30 60 (insulin sensitivity factor)

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• A correction dose of 1 unit of insulin would be
  expected to decrease the blood glucose by 60
  mg/dl. Patients should be taught to use their
  insulin sensitivity factor (this can be modified
  to 25), as follows
• Blood Glucose Target/Sensitivity Correction
  Dose
• If the premeal glucose is 198 mg/dl ( 90 mg/dl
  above the premeal target of 110 mg/dl), the
  patient would need to add 1.5 units of insulin to
  the bolus insulin dose.
• (198 110)/60 1.5 units
• J.D. would then add 1.5 units to his meal bolus
  dose to lower his glucose into his target range.
• It is important to note that this is just a
  starting point that must be assessed with
  follow-up blood glucose readings after the
  correction bolus is given

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500 Rule To Find Carb Factor

• Gives grams of carb covered by one unit of
  Humalog or Novolog
• 500 Rule provides a close estimate of carb factor
  if the TDD is accurate
• 500 / TDD grams of carb per unit of insulin
• Example
• Persons TDD 50 units
• 500/50 10 grams of carb covered by 1 unit of
  Humalog or Novolog
• Post meal readings stay normal!

1 gram of carb raises the BG 4 to 7 points!
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2000 Rule To Find Correction Factor

• Gives how far your blood glucose is likely to
  fall per unit of insulin over 5 hours
• 2000 / TDD mg/dl your BG will fall per unit
• Example
• Persons TDD 25 units
• 2000/25 an 80 mg/dl drop per unit of
  H or Nov
• 1600, 1800, 2000, or 2200 may be divided by TDD
  to get point drop per unit

• 1800 provides a good average -
• 1600 Rule is more aggressive and gives more
  insulin,
• while a 2000 or 2200 Rule gives less insulin

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New Devices

• Data storage and download
• Easy recording of BGs, insulin, carbs
• Automatic carb counting
• Pattern recognition
• Insulin dose guidance
• Data analysis to improve control
• Feedback that encourages use

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Pump Meter Combos

• CozMonitor from Deltec and Therasense
• Disetronic and Roche
• Medtronic 512 and BD Paradigm Link
• Animas and Life scan
• Dana Diabecare III and Dana meter

Sensor-augmented pump consisting of a Guardian RT
sensor (A), which is attached to a Minilink
transmitter (B) and they communicate with an
insulin infusion pump (C).
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The Big Three

• Medtronic Minimed
• Paradigm 508, 512 / 515, 712 / 715
• Animas Corp.
• IR1000, IR1200, IR1250
• Smiths Medical
• Deltec Cosmo
• Smart Pumps
• Insulin pump software will calculate mealtime
  insulin (bolus) based on
• Current blood glucose
• Carbohydrate content of the meal
• Previous bolus (time and size)

smart pump technology
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Advantages

• Precise doses, as small as 0.025 u, can be given
• Reminders
• Little risk of infection
• A freer lifestyle
• Easier dose determinations
• Improved blood sugars
• Flexibility in meal timing and size
• Ability to exercise without losing control
• Peace of mind
• Family activities are no longer tied to one
  persons needs
• Easier handling of illness, travel, or camping

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• Insulin Infusion Pumps and Exercise
• Normalize the glycemic and metabolic responses
  because insulin levels can be easily increased,
  decreased, or maintained at basal levels.
• In anticipation of exercise, insulin bolus can be
  adjusted.
• Self Blood Glucose Monitoring (SBGM) - important
  and helpful.

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• Disadvantages of IIP
• 10-15 minute delay in onset of insulin action
• Infusion site needs changing for every 3-4 days
• Always wearing a device
• Size of the infusion pump
• Vulnerability to trauma or disruption at the
  infusion site
• Must be removed for water sports

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Most Pump Problems Occur In

• First week
• First month
• First 6 months

Problems are most likely when unexpected or
inconvenient
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Occasional Pump Problems

• Allergies
• Bleeding
• onto skin
• inside needle
• under skin
• Pump bumps
• Dislodged infusion set

• Setup tips
• Leaks
• O-rings
• Hub
• Line
• Clogs
• Site infections

Some frustration at times is normal!
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Will Your Pump Alarm?
Yes Yes Yes Yes Yes No No No No

• Low battery
• Mechanical problem
• Empty reservoir
• Clog
• Forgotten bolus
• Leak
• Bleeding
• Bad programming
• Dislodged infusion set

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Pumps dont detect

• Disconnection
• Air in line
• Infection
• Leaks
• Abnormal tissue sites
• Infusion Site Problems
• Tissue abnormality
• Redness / pain / heat
• Hard tissue / scarring
• Kinked cannula
• Old site
• Improper depth / too near muscle / wrong angle
• Air in line
• Tube disconnected

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Problems with Infusion Pumps

• Out of insulin?
• Is the pump leaking?
• Is the connection between the tubing and the pump
  cartridge tight?
• Is the hub connection cracked?
• Can you smell insulin anywhere? (hint Insulin
  smells like Band Aids)
• Do the pump motor arms (MiniMed) or piston rod
  (Disetronic) move freely?

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Stocking of IIP

• Extra stock
• Keep refrigerated (36 - 46F). Discard after
  expiration
• Current bottle in use
• can be used for 30 days at room temp
• (59- 68F optimally, below 86F)

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Helpful Attitudes And Habits

• Be blatant about your diabetes
• A pump is a tool, not a cure
• Take a bolus for every bite
• Change site as directed
• Look for a solution for every problem
• BG Test often

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Conclusion

• A pump offers the latest technology for precise
  insulin delivery
• "Making the insulin pump available to Medicare
  beneficiaries will improve the quality of their
  lives. The infusion pump offers them a choice to
  better control their condition so that they are
  more active and productive,"
• Benefits include more flexibility, less
  hypoglycemia, improved control, and a longer,
  healthier lifespan
• Make the commitment and start pumping!

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If you are diabetic
use
and
Make ur life

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References

• A Randomized Trial Comparing Continuous
  Subcutaneous Insulin Infusion of Insulin Aspart
  Versus Insulin Lispro, DIABETES CARE, VOLUME 31,
  NUMBER 2, FEBRUARY 2008
• Insulin pump use in pediatrics, DIABETES CARE,
  VOLUME 30, NUMBER 6, JUNE 2007
• Classification of Distinct Baseline Insulin
  Infusion Patterns in Children and Adolescents
  With Type 1 Diabetes on Continuous Subcutaneous
  Insulin Infusion Therapy, DIABETES CARE, VOLUME
  30, NUMBER 3, MARCH 2007
• Comparison of apolipoprotein B100 metabolism
  between continuous subcutaneous and
  intraperitoneal insulin therapy in Type 1
  diabetes, Journal of Clinical Endocrinology
  Metabolism. published August 9, 2005 as
  doi10.1210/jc.2005-0989
• Bret berner, Steven M.Dinh Electornically
  Controllede Drug Delivery.
• Attia, N. Jones, T.W. Holcombe, J. and
  Tamborlane, W.V. Comparison of human regular
  and lispro insulins after interruption of
  continuous subcutaneous insulin infusion and in
  the treatment of acutely decompensated IDDM.
  Diabetes Care, Vol. 21, No. 5 pp. 81721, 1998.
• Comparison of Quality of Life in Diabetics Using
  Insulin Injection Therapy versus Subcutaneous
  Insulin Infusion Therapy by Katie Michele
  Reynolds et al 2007 Ypsilanti, Michigan

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References

• McCall A. In Insulin Therapy. Leahy J, Cefalu W,
  eds. New York, NY Marcel Dekker, Inc 2002193
• Jay S. Skyler, MD, MACP Steven Ponder, MD, FAAP,
  CDE Is There a Place for Insulin Pump Therapy in
  Your Practice? Volume 25, Number 2, 2007
  CLINICAL DIABETES
• www.delteccozmo.com
• www.diabeticcare.com
• www.childrenwithdiabetes.com
• www.diabetesnet.com
• www.animascorp.com
• www.myomnipod.com
• www.minimed.com

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THANK YOU