Presentation on theme: "Presented by Susie Heaton, MS, RD, CDE. Basal rates Insulin to Carbohydrate Ratio (I:C) Insulin Sensitivity Factor (ISF) Pump Download and History Infusion."— Presentation transcript:
Presented by Susie Heaton, MS, RD, CDE
Basal rates Insulin to Carbohydrate Ratio (I:C) Insulin Sensitivity Factor (ISF) Pump Download and History Infusion site issues Combo Bolus Case Studies
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
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.
What to doWhen 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.
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.
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
Make adjustments in unit increments 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
Time10 pm12 am3 am6 am BG test # BG test # BG test # Basal0.550
Decrease basal at 12 am to 0.450
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
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
What to doWhen 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
ResultAdjustment 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) 4-5 hours after CHO bolus:
Make changes in 1 gram increments If I:C is less than 1:5 Make changes in 2 gram increments If I:C is between 1:5- 1:20 Make changes in 5 gram increments If I:C is between 1:20- 1:50 Make changes in 10 gram increments If I:C is more than 1:50
BGBefore Meal 1 hr pp2 hr pp3 hr pp4 hr pp5 hr pp Day Day Day Breakfast I:C 1:15
Change I:C to 1:13 Or bolus for breakfast 20 to 30 minutes before breakfast
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
ISF indicates how much (mg/dL) 1 unit of rapid-acting insulin will lower BG Determine starting point: 1500 or 1800 ÷ TDD (Total Daily Dose) = ISF Example: 1800 ÷ 40 U = 45 ISF May have more than one ISF for different times of day
What to doWhen 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
Make adjustments in 5 mg/dl increments If ISF is less than 20 Make adjustments in 10 mg/dl increments If ISF is between Make adjustments in 20 mg/dl increments If ISF is greater than 100
ISF 1:50High before correction 1 hour post correction 2 hour post correction 3 hour post correction 4hour post correction Correction # Correction # Correction #
Change ISF to 1:40
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
Bolus Amounts Frequency Type Basal vs Bolus 50:50 How much insulin need for a prescription Alarms Prime Suspend
Infusion site Change frequency Rotation Adherence Pain or Discomfort Bent Cannula Frequency Look for signs of overuse Bolus timing and type 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
FoodDurationRatio Fast Food, Movie Popcorn, And high fat desserts 1 hour50:50 Mexican, Chinese, Italian, Steak dinner, Buffets 2 hour50:50 Pizza3 hour50:50 * These are suggested starting points
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?
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.
The purpose of the 4 hour check is to determine if the 2 nd 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
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.
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
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
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
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.
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
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
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
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