1. Insulin Pump Management
Presented by Susie Heaton, MS, RD, CDE

2. Pump Settings to Evaluate
Basal rates
Insulin to Carbohydrate Ratio (I:C)
Insulin Sensitivity Factor (ISF)
Pump Download and History
Infusion site issues
Combo Bolus
Case Studies

3. Basal Rates
Basal rates that are set correctly should keep your BG relatively stable in the absence of food, exercise or extra insulin
Basal rates should be evaluated when there is variability in BG readings, change of season, significant weight changes or change in physical status

4. Basal Testing Tips
Divide day into 4 time frames and evaluate one time frame at a time.
Evaluations begin 4-5 hours after the last bolus dose and food consumption.
Starting bg should be around mg/dl
Testing is stopped if bg goes above 150 or below 90.
Repeat test 2-3 times before making adjustments.

5. Basal Rate Test: Overnight
What to do
When to test
Eat dinner (low fat, known carbohydrate content meal)
Bolus for dinner
Nothing to eat until breakfast
4 hours after dinner
At bedtime
At midnight
At 2-3 am
Every 3 hours when awake
BG must be in target range four hours after dinner to start this test.

6. Basal Rate Test: Daytime
What to do
When to test
Morning
Skip breakfast
No food until lunch
Test every 1-2 hours until lunch
Afternoon
Skip lunch
No food until dinner
Start to test 4 hours after breakfast
Test every 1-2 hours until dinner
Evening
Skip dinner
No food until bedtime
Start to test 4 hours after lunch
Test every 1-2 hours until bedtime
BG must be in target range four hours after meal to start test. Each daytime segment should be tested on a different day.

7. Looking at the Data
BG swings of more than 30 mg/dl indicates the need for basal adjustments
It is best to see repeating trends before making changes
Basal rate should be increased or decreased 1-2 hours before the BG begins to rise or fall.
Make one change at a time

8. Suggested Guidelines for Basal Adjustments
Basal of 2.0 units per hour or more
Make adjustments in unit increments
Basal of units per hour
Make adjustments in unit increments
Basal of units per hour
Make adjustments in unit increments
Basal less than 0.3 units per hour
Make adjustments in unit increments

9. What should we do? Time 10 pm 12 am 3 am 6 am BG test #1 149 130 86 61
131
119 77 59
BG test #3
122
110 73 55
Basal
0.550

10. Suggested Changes
Decrease basal at 12 am to 0.450

11. Calculating I:C Ratio
I:C indicates how many grams of carbohydrate 1 unit of rapid-acting insulin will cover
Determine starting point for I:C ratio 500 ÷ TDD (Total Daily Dose) = I:C Example: 500 ÷ 50 U = 10 (I:C= 1:10)
May have more than one I:C for different meals or times of day

12. Insulin to Carbohydrate (I:C) Ratio
After basal settings have been confirmed, you can evaluate bolus dosages
If the BG consistently returns to target range about 4 hours after meals, you can be confident that the I:C ratio is working well
If the BG does not return to target range 4 hours after meals, you should evaluate the I:C ratio

13. Checking I:C Ratio What to do When to test Start before meal
Assure BG in target range ( mg/dl)
Assure known amount of carbohydrate and low fat meal
Bolus for meal
Test BG hourly for 5 hours
Recommended Goals
1 hour after meal
BG mg/dL higher than pre-meal
4 hours after meal
BG within 30 mg/dL of pre-meal

14. Adjusting I:C Ratio 4-5 hours after CHO bolus: Result Adjustment
BG more than 30 mg/dL below pre-meal
Re-check ratio another time using a higher I:C (higher I:C will reduce size of bolus)
BG within 30 mg/dL of start
Carbohydrate ratio is correct
BG more than 30 mg/dL above start
Re-check ratio another time using a lower I:C (lower I:C will increase the size of the bolus)

15. Suggested Guidelines for I:C Ratio Adjustments
If I:C is less than 1:5
Make changes in 1 gram increments
If I:C is between 1:5- 1:20
Make changes in 2 gram increments
If I:C is between 1:20- 1:50
Make changes in 5 gram increments
If I:C is more than 1:50
Make changes in 10 gram increments

16. What should we do? BG Before Meal 1 hr pp 2 hr pp 3 hr pp 4 hr pp
Day 1 99
220
181
176
153
151
Day 2
121
277
205
188
185
Day 3
1 07
256
230
194
183
Breakfast I:C
1:15

17. Suggested Changes Change I:C to 1:13
Or bolus for breakfast 20 to 30 minutes before breakfast

18. Insulin Sensitivity Factor (ISF)
Once you have confirmed basal settings and bolus dosages for carbohydrate, you can evaluate ISF
The goal is for the ISF to return from a BG above target to the target range within 4 hrs of a correction bolus

19. Calculating ISF
ISF indicates how much (mg/dL) 1 unit of rapid-acting insulin will lower BG
Determine starting point: or 1800 ÷ TDD (Total Daily Dose) = ISF Example: ÷ 40 U = 45 ISF
May have more than one ISF for different times of day

20. Evaluating ISF What to do When to test
Give a correction dose of insulin for high BG
Test BG hourly for 4 hours
Recommended Goals
4 hours after bolus
BG in target
3.5 hours after bolus
BG should decrease within 30 mg/dL of target at 3.5 hours for rapid-acting insulin

21. Suggested Guidelines for ISF Ratio Adjustments
If ISF is less than 20
Make adjustments in 5 mg/dl increments
If ISF is between
Make adjustments in 10 mg/dl increments
If ISF is greater than 100
Make adjustments in 20 mg/dl increments

22. What should we do? ISF 1:50 High before correction
1 hour post correction
2 hour post correction
3 hour post correction
4hour post correction
Correction #1
350
322
230
199
201
Correction #2
375
335
301
275
242
Correction #3
250
180
165
150
155

23. Suggested Changes
Change ISF to 1:40

24. Do You Download? Look for BG trends Number of BG readings Average BG
Site changes – cannula fill
Bolus frequency
Carbs
Bolus vs. basal
Frequent alarms (empty cartridge, suspend)
Current Pump Settings

25. Look in the History of the Pump
Bolus
Amounts
Frequency
Type
Basal vs Bolus
50:50
How much insulin need for a prescription
Alarms
Prime
Suspend

26. What else do we assess? Infusion site Bolus timing and type
Change frequency
Rotation
Adherence
Pain or Discomfort
Bent Cannula Frequency
Look for signs of overuse
Bolus timing and type
Combo bolus

27. Combo Bolus Also known as a square or dual wave bolus
Used as a bolus to cover slower absorbed meals that contain higher protein and fat content
Such as with meals that include buffets, restaurant dining, and pizza
Need to decide duration and ratio when using

28. When to use a Combo Bolus?
Food
Duration
Ratio
Fast Food, Movie Popcorn,
And high fat desserts
1 hour
50:50
Mexican, Chinese, Italian, Steak dinner, Buffets
2 hour
Pizza
3 hour
*These are suggested starting points

29. Evaluating a Combo Bolus
Do Premeal BG – start trial if BG within normal range ( mg/dl)
Determine carbs give and program combo bolus
Monitor BG hourly to evaluate for up to 6 hours
Did the BG return to within 30 mg/dl of the target range within 6 hours?

30. The 2 hour BG check
The purpose of the 2 hour check is to determine if the first portion of the bolus was the correct amount to maintain normal BG 2 hours after the meal
If the 2 hour BG is high try a 60:40 split next time continue to make adjustments until the right combination is reached.
If the 2 hour BG is low try 40:60 split next time.

31. The 4 hour BG check
The purpose of the 4 hour check is to determine if the 2nd portion of the bolus was the correct amount to maintain normal BG 4 hours after the meal
If the 4 hour BG is high increase the amount of insulin given over the extended portion of the bolus

32. The 6 hour BG check
The purpose of the 6 hour check is to see if the second portion of the bolus was the correct amount of insulin and the right length of time
If the BG was normal at the 4 hour check but high a the 6 hour check the extended portion of the bolus may need to be increased.

33. Putting it into practice

34. 12 year old male – A1c 10.5%
HCP sends pt to the educator for carb counting review
Has been on pump for 2 years
Patient comes in with both parents
Parents express concerns and frustrations accusing child of sneaking food and not bolusing
Patient is quiet and pouty

35. What things should we assess?
Have orders from HCP that allows you to make dosage adjustments
Review Daily routine – assess carb counting ability.
Download pump or look in history
Bolus, bg testing results, site change frequency
Other

36. Results of Assessment
Found carb counting ability to be adequate, but often guessing amounts
After reviewing pump data we find that the patient has been bolusing for meals and snacks
BG logs reveal that pt is testing frequently as most results are above target range
Basal vs. Bolus reveals that patient is constantly trying to correct bg. Basal is only 30% 0f Total Daily Dose

37. Plan for 12 year old male
Improve Carb Counting accuracy by measuring portions, reading food labels, and using the smart features on the pump to calculate bolus doses
Praise patient for bolusing and testing frequency
Let him know that he is growing and he just needs more insulin.
Do a 10% increase on basal immediately
Instruct family on basal testing and ask them to send in results in 1 week for needed basal adjustments or make 1 week f/u appointment.

38. 32 yo Female – A1c 8.8% She works full time and has 3 young children
Both the HCP and patient are frustrated with the poor bg control
She is fearful of lows - hx of severe hypoglycemic event 3 years ago
Has been on pump for 6 years

39. What things should we assess?
Have orders from HCP that allows you to make dosage adjustments
Review Daily routine
Download pump or look in history
Bolus – frequency and timing, bg testing frequency and results, site change frequency and rotation
other

40. Results of Assessment
Daily routine reveals that life is chaotic and lacks a consistent schedule and as a mom she puts herself last
Dine out frequently
Pump download reveals
boluses and bg testing infrequent often only 1-2 per day
Not using the pump bolus calculator features or combo bolus when dining out
Changing site every 4-5 days when cartridge runs out
Has only used abdomen for infusion site area

41. Plan for 32 yo female Set reminders on pump to bolus
Discuss and instruct pt on benefits of using the bolus calculating features on the insulin pump including the combo bolus (for dining out)
Discuss the importance of site change frequency and rotation. Suggest she only fill her cartridge with a 3 day supply of insulin. Have pt use a alternate infusion site area and leave abdomen area alone for at least 3 months.
Discuss benefits of a CGM