1. Pumping How Do I Start? John Walsh, P.A.
Author: Pumping Insulin, Using Insulin
(619)

2. What We’ll Cover Introduction to pumps Advantages of pumping
Am I a candidate?
How to choose a pump and infusion set
What is needed to start
Importance of data
Site preparation
Troubleshooting
Formulas that help
Smart features

3. Where Pumps Began
Started ~1978 with conversion of portable chemotherapy pumps to delivery of insulin
The Autosyringe AS2C and Harvard Apparatus Mill Hill Infuser were first
Single basal, no memory
50 ml syringe on pump exterior
Required dilution of insulin to U-36 or U-18
1976 Biostator (top) and 1978 Autosyringe AS2C –>

4. The Basal-Bolus Concept

5. Advantages Flexibility in meal timing & size Eat when you want to
Beginning Pumping
Advantages
Flexibility in meal timing & size
Eat when you want to
Faster adjustment of insulin for exercise
Family activities are no longer tied to one person’s needs
Easier handling of illness, travel, or camping
A normal lifestyle is easier when insulin can be delivered as needed.

6. Advantages More Consistent Insulin Action
The same dose of NPH insulin given to the same individual varies by 25% from day to day
Order of variablility: NPH > Lente > Lantus > Detemir
A pump has less variable insulin delivery at 3%

7. Advantages Precise doses, as small as 0.025 u, can be given
Manages the Dawn Phenomenon
Improves control during growth spurts and adolescence
Reminders

8. Who Is A Good Pump Candidate?

9. Why Choose A Pump? A freer lifestyle Easier dose determinations
Improved blood sugars
Flexibility in meal timing and size
Ability to exercise without losing control
Peace of mind

10. When To Consider A Pump More than 3 injections per day
Beginning Pumping
When To Consider A Pump
More than 3 injections per day
Tired of multiple injections
Frequent or severe hypoglycemia
Hypoglycemia unawareness
Elevated A1c
DKA or ER/hospital admission
Strong Dawn Phenomenon
Require small, precise doses
Less risk of complications
Insulin pumps have tremendous advantages for precise, flexible insulin delivery.

11. Insulin Pump Pro Less work Simplified insulin dosing Precise delivery
Greater impact in those with highest starting A1c
Slightly less insulin use per day
Con
More DKA
More severe hypoglycemia
A1c levels and frequency of DKA & hypoglycemia are similar to ICT

12. What It Takes To Succeed
Beginning Pumping
What It Takes To Succeed
A personal desire for better control
Willing to adjust insulin doses to carb count, test results, and activity
Willing to monitor at least 4 times a day
Willing to keep an accurate record of BGs, boluses, and carb counts
Committed to solve problems and adapt lifestyle as needed
An insulin pump is only a good tool. Success comes from using the tool well, and coordinating all the data that allows insulin doses from the pump to match carbs and lifestyle.

13. Success For Kids On Pumps
Supervision is required: kids BEGIN to develop self care skills at about age 10
Family support is essential: an adult who can go to school, etc.
Communication with a health care team that is committed to pumps
Adequate insurance and financial resources
Assistance and support from teachers, friends, babysitters, grandparents, siblings

14. Features For Infants & Toddlers
Little ones are ideal pump candidates if the parents are
Delay or split boluses for fussy eaters
Small, user-friendly pumps offer precise dosing (0.05, 0.025, or 0.01 unit increments)
Lock out
Worn between shoulder blades
If a toddler likes to remove the infusion set, let them know what comes out must go right back in

15. Help For Kids & Teens Growth spurts Dawn Phenomenon
Easy coverage of snacks
TDD and bolus history can be checked to ensure consistent dosing
Faster adjustment of basals and boluses for changes in activity, etc

16. Special Teen Concerns Dating Wearing, sharing Alcohol Eating disorders
Fast foods
Fabrication
Sleeping-in

17. Learn how to adjust your basals and boluses for an excellent A1c!
Personal Effort
Those who expect a pump to manage their diabetes for them will fail to optimize their own therapy.
Learn how to adjust your basals and boluses for an excellent A1c!

18. First Steps Toward A Pump
Keep detailed records
Consider your (and your child’s) motivation
Peer group, acceptance issues, family support
Look at available pumps
Which pump(s) does your insurance cover?
Talk with your doctor about a prescription
Visit a dietician to learn carb counting

19. What To Learn How your pump works How to count carbs
How to interpret BG results and see BG patterns
When to increase and decrease basals and boluses
How to adjust for high GI foods, extra activity

20. How To Choose A Pump

21. Pump Companies Who sell or plan to sell pumps in the US: Animas R1200
Dana Diabecare III
Deltec Cozmo
Medtronic Paradigm
Nipro Amigo
Roche/Disetronic
Visit

22. Things To Consider Look, feel, color
Features: reminders, child block, waterproofing
Size of basal and bolus increments
Infusion set choices
Safety and reliability
Customer support
History
Ease of data analysis
Add-ons: meters, covers, cases

23. Today’s Smart Pumps
Easy dose calculations with Carb Factor and Correction Factor
Precise insulin dosing (0.05 units or better) to allow basal rates to be set up for Dawn Phenomenon, etc.
Tracks BOB to avoid insulin stacking
Reminders

24. Today’s Pumps
When control is poor or varies greatly on one of today’s pumps, the pump settings are incorrect.
Test and reset basal rates, carb and correction factors until you have good control.
Garbage in…..

25. How To Choose An Infusion Set

26. Infusion Sets Straight-In Teflon: Cleo, Inset, Ultraflex, Quik-Set
Easier to insert, variety of depths (6, 8, 9 mm)
Angled Teflon (Comfort, Tender, Easy, Silhouette):
Fewer failures
Insertion site is visible
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

27. Infusion Sets And Inserters
Disetronic Rapid-D
Smith’s Medical Cleo
Animas Inset
Medtronic Sil-serter
Quik-serter

28. Site Supplies Emla cream (Rx, 30 min wait) or ice cube
Set inserter: Cleo and Inset are self-contained, ezSerter, Quick-Serter, Sil-Serter, Sof-Serter
Adhesive: IV-3000, Hypafix, Tegaderm
Stickies: Skin Tac-H, Skin Prep
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

29. School Supplies Meter, lancets, test strips
Glucagon, glucose tablets, or crackers for lows
Spare insulin, syringes or insulin pen
Spare infusion set and pump batteries
Ketostix or Precision Xtra to test for ketones
Information card with insulin-to-carb ratio, formula for corrections
Telephone numbers of parents, health care providers, and pump manufacturer's help line

30. How To Start

31. Starting On A Pump Everyone is nervous Read, read, read
Beginning Pumping
Starting On A Pump
Everyone is nervous
Read, read, read
Pumping Insulin, Kids Insulin Pumps And You (Animas), etc, etc
Do lots of recording before and after start
Start to play with pump as soon as it arrives
Saline practice helps
Get telephone contacts: MD, CDE, pump company, pump rep, other parents
Nervousness is normal. If you have access to your pump before the pump start, be sure to take it out of the box and push all the buttons as you watch the pump video. You cannot learn too much and you won’t hurt the pump. Load a reservoir saline if you have some and insert the infusion set. Otherwise, load the reservoir with water, prime the tubing, etc, but don’t insert the infusion set. This practice does not qualify you to start a pump, but can make your pump start much easier and quicker.

32. 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
Write down a reason for every low and high
Test often

33. J Walsh and R Roberts: Pumping Insulin, 2005
John’s Pump Rules
Total Daily Dose = weight in lbs / 4
Basal Dose = 50% to 60% of TDD
Carb Factor = 500 / TDD
Correction Factor = 2000 / TDD
BG target = 90 to 120 mg/dl
Basal target = +/- 30 mg/dl
BOB = 20% per hour
Correction boluses = < 8% of TDD
J Walsh and R Roberts: Pumping Insulin, 2005

34. Starting Insulin Doses
J Walsh and R Roberts: Pumping Insulin, 2005

35. Carb Counting And Recording As Ways To Lower The A1c

36. Steps For A Better A1c Carb counting – 0.6%
Givivg boluses based on an accurate carb count – 0.3%
Recording test results, carb intake, insulin doses, & activity – 0.5%
Monitoring often – %
Bolusing often – %
Contacting your doctor or adjusting your own doses when you encounter unwanted BGs

37. Carb Counting Allows precise matching of carbs with boluses
Beginning Pumping
Carb Counting
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!
A great control tool!

38. Where Carbs Come From fruit/fruit juice breads/bagels cereals crackers
Beginning Pumping
Where Carbs Come From
fruit/fruit juice
breads/bagels
cereals
crackers
grains
muffins
rice
potatoes/yams
vegetables
dessert/cookies/cake/pie
ice cream/frozen dessert
sweetened beverages
milk/yogurt (not cheese)
beer/wine
honey/syrup/molasses
jams/jellys/preserves
-ose foods like sucrose (table sugar)
1 gram of carb
raises the BG
4 to 7 points!
Most of the things that contain carbs. A good thing to remember when you have a low is that one gram of carb will raise your blood sugar about 4 mg/dl (0.22 mmol). Someone who is heavier may go up only 3 mg/dl, while a child who weighs 70 lbs. may find they rise 6 mg/dl or so.

39. How To Count Carbs Food labels Books A gram scale plus carb factors
Beginning Pumping
How To Count Carbs
Food labels
Check portion size
Books
Dr’s Pocket Guide, Health Cheques
A gram scale plus carb factors
Carb factors are available in Pumping Insulin and are built into scales like the Salter computer gram scale
There are many ways to count carbs.

40. Blood Sugar Testing – 1921

41. Beginning Pumping
Blood Sugar Testing – 2004

42. Beginning Pumping
Blood Sugar Testing – 2004
“I just don't write down (log) anything. I hate to take the time to do it. I'd rather have a machine talk for me. I think it revolves around partial general laziness, as well as the constant reminder of being different from everyone else. I know other diabetics who won't even test when they're out with friends. They hate ….”
The Artiste 6/28/04

43. Charting Improves Control
Beginning Pumping
Charting Improves Control
Smart Charts
Needed to solve problems
Basis for better diabetes health care
~0.5% drop in A1c
Smart Charts are one of several good charting tools to keep track of why your readings are changing.
Blood sugar, insulin, food, activity, stress

44. Better Charts, Better A1c
Beginning Pumping
Better Charts, Better A1c
Charts
My Other CheckBook
Software
Meter companies
Internet: myhealthchannel.com
Pump Control Software
Meters, PDAs & Pumps
Pump: Deltec, Disetronic, Animas, Medtronic
Meter: BD, Therasense, Lifescan, Boerhinger

45. Analyze Carb Boluses Count carbs Give carb bolus Eat Record BGs
Beginning Pumping
Analyze Carb Boluses
Count carbs
Give carb bolus
Eat
Record BGs
Analyze BGs
Balance better next time

46. Match Your Carbs With Boluses
Beginning Pumping
Match Your Carbs With Boluses
Accounts for HALF the day’s control!
Keeps blood sugar normal after meals
Requires accurate carb counting and an accurate carb factor
500 Rule provides a close estimate of carb factor if the TDD is accurate
Once basals have been set and tested, carb coverage is the other elephant in control. Carb counting or a consistent carb intake allows boluses to be matched for good post meal readings, and fewer highs and lows.

47. 500 Rule To Find Carb Factor
Beginning Pumping
500 Rule To Find Carb Factor
Gives grams of carb covered by one unit of Humalog or Novolog
500 / TDD = grams of carb per unit of insulin
Example:
Person’s TDD = 50 units
500/50 = 10 grams of carb covered by unit of Humalog or Novolog
Postmeal readings stay normal!
I developed the 500 Rule (originally the 450 Rule for Regular insulin) to give a close estimate for how many carbs one unit of insulin would cover.

48. 2000 Rule To Find Correction Factor
Beginning Pumping
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:
Person’s TDD = 25 units
2000/25 = an 80 mg/dl drop per unit of H or Nov
1800 (Some use 1900, 2000, or 2200) is another magic number that gives how far your blood sugar will drop per unit of analog insulin. This allows a sliding scale to be set up safely.
Adapted from 1500 Rule by Dr. Paul Davidson, Atlanta, GA

49. Beginning Pumping
2000 Rule
1600, 1800, 2000, or 2200 may be divided by TDD to get point drop per unit
This table shows how the point drop relates to the TDD.
1800 provides a good average Rule is more aggressive and gives more insulin, while a 2000 or 2200 Rule gives less insulin

50. New Devices Data storage and download
Beginning Pumping
New Devices
Data storage and download
Easy recording of BGs, insulin, carbs, activity
Automatic carb counting
Pattern recognition
Insulin dose guidance
Data analysis to improve control
Feedback that encourages use
The lack of clear pattern analysis is one of the great failings of meters. Wouldn’t it be nice if your meter told you that you are having too many lows or highs, or that you seem to be eating too much when you go low because your next reading is too high? A few of many examples that could be given. Self responsibility is one thing, not being able to easily make use of existing information is another.

51. Pump — Meter Combos CozMonitor from Deltec and Therasense
Disetronic and Roche
Medtronic 512 and BD Paradigm Link
Animas and Lifescan
Dana Diabecare III and Dana meter

52. Troubleshooting

53. Most Pump Problems Occur In
Beginning Pumping
Most Pump Problems Occur In
First week
First month
First 6 months
Experience is the great teacher. Problems will occur and unanswered questions will pop up. Problems with basal and bolus doses, as well as the “what do I do when…” questions will largely appear in the first week. Other issues, such as clothing styles and sets falling out usually appear in the first month. More serious questions about ketoacidosis and unexplained highs will usually be encountered in the first six months. Most pumpers will have encountered most problem situations in the first 6 to 12 months.
Frustration may occur when high blood sugars are encountered, but the source for the problem cannot be immediately identified, or when sets fall out after swimming or showering.
Problems are most likely when
unexpected or inconvenient

54. Occasional Pump Problems
Beginning Pumping
Occasional Pump Problems
Setup tips
Leaks
O-rings
Hub
Line
Clogs
Site infections and abscesses
Allergies
Bleeding
onto skin
inside needle
under skin
Pump bumps
Hypertrophy
DKA
Some frustration at times is normal!

55. Set And Site Issues Dislodged infusion set Tunnelling Infection
Beginning Pumping
Set And Site Issues
Dislodged infusion set
Tunnelling
Rapid-D and slanted Teflon sets work better for mobile kids
Metal may be better than teflon
Infection
Hematoma

56. 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

57. Will Your Pump Alarm? Low battery Mechanical problem Empty reservoir
Beginning Pumping
Will Your Pump Alarm?
Low battery
Mechanical problem
Empty reservoir
Clog
Forgotten bolus
Leak
Bleeding
Bad programming
Dislodged infusion set
Yes No

58. How To Check Mechanical Problems
Beginning Pumping
How To Check Mechanical Problems
Skin and site
Infusion set
Connection
Line
Hub
Reservoir
Pump
Check from
skin to pump:

59. High BG Checklist See a leak or smell insulin? Infusion set in place?
Was infusion set primed?
Are connections at hub and O-rings tight?
Bubbles in the tubing? One inch = a half unit
Clog in line?
Alarms? Errors?
If no cause is found, replace everything!

60. Go to ER at 1st sign of vomiting!
Beginning Pumping
Check Ketones Early
Test for all BGs over 300
Always test when nauseous
Test urine with Ketodiastix
Test blood with Precision Xtra meter
Earlier detection
No need to collect urine
Keep currently dated strips available
Go to ER at 1st sign of vomiting!

61. More Insulin For Unexplained High BGs
When a blood glucose test is unexpectedly high, the correction bolus needed to lower this will be much higher than normally required
Loss of basal insulin delivery for several hours
Insulin resistance from length of hyperglycemia
Insulin resistance from presence of ketones

62. Conclusion
A pump offers the latest technology for precise insulin delivery
Requires commitment and responsibility
Benefits include more flexibility, less hypoglycemia, improved control, and a longer, healthier lifespan
Make the commitment and start pumping!

63. Questions ???