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Pumping How Do I Start? John Walsh, P.A. Author: Pumping Insulin, Using Insulin (619) 497-0900 www.diabetesnet.com www.diabetesnet.com.

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Presentation on theme: "Pumping How Do I Start? John Walsh, P.A. Author: Pumping Insulin, Using Insulin (619) 497-0900 www.diabetesnet.com www.diabetesnet.com."— Presentation transcript:

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

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

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

4 The Basal-Bolus Concept

5 Advantages Flexibility in meal timing & size Flexibility in meal timing & size Eat when you want to Eat when you want to Faster adjustment of insulin for exercise Faster adjustment of insulin for exercise Family activities are no longer tied to one persons needs Family activities are no longer tied to one persons needs Easier handling of illness, travel, or camping Easier handling of illness, travel, or camping

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

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

8 Who Is A Good Pump Candidate?

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

10 When To Consider A Pump More than 3 injections per day More than 3 injections per day Tired of multiple injections Tired of multiple injections Frequent or severe hypoglycemia Frequent or severe hypoglycemia Hypoglycemia unawareness Hypoglycemia unawareness Elevated A1c Elevated A1c DKA or ER/hospital admission DKA or ER/hospital admission Strong Dawn Phenomenon Strong Dawn Phenomenon Require small, precise doses Require small, precise doses Less risk of complications Less risk of complications

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

12 What It Takes To Succeed A personal desire for better control A personal desire for better control Willing to adjust insulin doses to carb count, test results, and activity Willing to adjust insulin doses to carb count, test results, and activity Willing to monitor at least 4 times a day Willing to monitor at least 4 times a day Willing to keep an accurate record of BGs, boluses, and carb counts Willing to keep an accurate record of BGs, boluses, and carb counts Committed to solve problems and adapt lifestyle as needed Committed to solve problems and adapt lifestyle as needed

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

14 Features For Infants & Toddlers Little ones are ideal pump candidates if the parents are Little ones are ideal pump candidates if the parents are Delay or split boluses for fussy eaters Delay or split boluses for fussy eaters Small, user-friendly pumps offer precise dosing (0.05, 0.025, or 0.01 unit increments) Small, user-friendly pumps offer precise dosing (0.05, 0.025, or 0.01 unit increments) Lock out Lock out Worn between shoulder blades Worn between shoulder blades If a toddler likes to remove the infusion set, let them know what comes out must go right back in 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 Growth spurts Dawn Phenomenon Dawn Phenomenon Easy coverage of snacks Easy coverage of snacks TDD and bolus history can be checked to ensure consistent dosing TDD and bolus history can be checked to ensure consistent dosing Faster adjustment of basals and boluses for changes in activity, etc Faster adjustment of basals and boluses for changes in activity, etc

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

17 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 Keep detailed records Consider your (and your childs) motivation Consider your (and your childs) motivation Peer group, acceptance issues, family support Peer group, acceptance issues, family support Look at available pumps Look at available pumps Which pump(s) does your insurance cover? Which pump(s) does your insurance cover? Talk with your doctor about a prescription Talk with your doctor about a prescription Visit a dietician to learn carb counting Visit a dietician to learn carb counting

19 What To Learn How your pump works How your pump works How to count carbs How to count carbs How to interpret BG results and see BG patterns How to interpret BG results and see BG patterns When to increase and decrease basals and boluses When to increase and decrease basals and boluses How to adjust for high GI foods, extra activity 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 Animas R1200 Dana Diabecare III Dana Diabecare III Deltec Cozmo Deltec Cozmo Medtronic Paradigm Medtronic Paradigm Nipro Amigo Nipro Amigo Roche/Disetronic Roche/Disetronic Visit

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

23 Todays Smart Pumps Easy dose calculations with Carb Factor and Correction Factor 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. 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 Tracks BOB to avoid insulin stacking Reminders Reminders

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

25 How To Choose An Infusion Set

26 Infusion Sets Straight-In Teflon: Cleo, Inset, Ultraflex, Quik-Set Straight-In Teflon: Cleo, Inset, Ultraflex, Quik-Set Easier to insert, variety of depths (6, 8, 9 mm) Easier to insert, variety of depths (6, 8, 9 mm) Angled Teflon (Comfort, Tender, Easy, Silhouette): Angled Teflon (Comfort, Tender, Easy, Silhouette): Fewer failures Fewer failures Insertion site is visible Insertion site is visible Longer is more secure Longer is more secure Adjust angle to reach fat Adjust angle to reach fat Metal needles (Rapid-D or bent needle) Metal needles (Rapid-D or bent needle) As comfortable and often more reliable As comfortable and often more reliable Very short, multi-needle infusion sets expected soon Very short, multi-needle infusion sets expected soon

27 Infusion Sets And Inserters Smiths Medical Cleo Medtronic Sil-serter Disetronic Rapid-D Animas Inset Quik-serter

28 Site Supplies Emla cream (Rx, 30 min wait) or ice cube Emla cream (Rx, 30 min wait) or ice cube Set inserter: Cleo and Inset are self-contained, ezSerter, Quick-Serter, Sil-Serter, Sof-Serter Set inserter: Cleo and Inset are self-contained, ezSerter, Quick-Serter, Sil-Serter, Sof-Serter Adhesive: IV-3000, Hypafix, Tegaderm Adhesive: IV-3000, Hypafix, Tegaderm Stickies: Skin Tac-H, Skin Prep Stickies: Skin Tac-H, Skin Prep Tape: Micropore, Durapore, Band-Aid Blister Relief (wicking) Tape: Micropore, Durapore, Band-Aid Blister Relief (wicking) Sweating aid: Mastisol Spray (Detachol for removal), Skin Tac, Tincture of Benzoin, Skin Prep Sweating aid: Mastisol Spray (Detachol for removal), Skin Tac, Tincture of Benzoin, Skin Prep Adhesive removal: Uni-Solve, Allkare Adhesive removal: Uni-Solve, Allkare

29 School Supplies Meter, lancets, test strips Meter, lancets, test strips Glucagon, glucose tablets, or crackers for lows Glucagon, glucose tablets, or crackers for lows Spare insulin, syringes or insulin pen Spare insulin, syringes or insulin pen Spare infusion set and pump batteries Spare infusion set and pump batteries Ketostix or Precision Xtra to test for ketones Ketostix or Precision Xtra to test for ketones Information card with insulin-to-carb ratio, formula for corrections Information card with insulin-to-carb ratio, formula for corrections Telephone numbers of parents, health care providers, and pump manufacturer's help line 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 Everyone is nervous Read, read, read Read, read, read Pumping Insulin, Kids Insulin Pumps And You (Animas), etc, etcPumping Insulin, Kids Insulin Pumps And You (Animas), etc, etcwww.childrenwithdiabetes.com Do lots of recording before and after start Do lots of recording before and after start Start to play with pump as soon as it arrives Start to play with pump as soon as it arrives Saline practice helps Saline practice helps Get telephone contacts: MD, CDE, pump company, pump rep, other parents Get telephone contacts: MD, CDE, pump company, pump rep, other parents

32 Helpful Attitudes And Habits Be blatant about your diabetes Be blatant about your diabetes A pump is a tool, not a cure A pump is a tool, not a cure Take a bolus for every bite Take a bolus for every bite Change site as directed Change site as directed Look for a solution for every problem Look for a solution for every problem Write down a reason for every low and high Write down a reason for every low and high Test often Test often

33 Johns Pump Rules Total Daily Dose = weight in lbs / 4 Total Daily Dose = weight in lbs / 4 Basal Dose = 50% to 60% of TDD Basal Dose = 50% to 60% of TDD Carb Factor = 500 / TDD Carb Factor = 500 / TDD Correction Factor = 2000 / TDD Correction Factor = 2000 / TDD BG target = 90 to 120 mg/dl BG target = 90 to 120 mg/dl Basal target = +/- 30 mg/dl Basal target = +/- 30 mg/dl BOB = 20% per hour BOB = 20% per hour Correction boluses = < 8% of TDD 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% Carb counting – 0.6% Givivg boluses based on an accurate carb count – 0.3% Givivg boluses based on an accurate carb count – 0.3% Recording test results, carb intake, insulin doses, & activity – 0.5% Recording test results, carb intake, insulin doses, & activity – 0.5% Monitoring often – % Monitoring often – % Bolusing often – % Bolusing often – % Contacting your doctor or adjusting your own doses when you encounter unwanted BGs Contacting your doctor or adjusting your own doses when you encounter unwanted BGs

37 Carb Counting Allows precise matching of carbs with boluses 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 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! Easy!

38 Where Carbs Come From fruit/fruit juice fruit/fruit juice breads/bagels breads/bagels cereals cereals crackers crackers grains grains muffins muffins rice rice potatoes/yams potatoes/yams vegetables vegetables 1 gram of carb raises the BG 4 to 7 points! 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)

39 How To Count Carbs Food labels Food labels Check portion size Check portion size Books Books Drs Pocket Guide, Health Cheques Drs Pocket Guide, Health Cheques A gram scale plus carb factors A gram scale plus carb factors Carb factors are available in Pumping Insulin and are built into scales like the Salter computer gram scale Carb factors are available in Pumping Insulin and are built into scales like the Salter computer gram scale

40 Blood Sugar Testing – 1921

41 Blood Sugar Testing – 2004

42 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 Smart Charts Needed to solve problems Needed to solve problems Basis for better diabetes health care Basis for better diabetes health care ~0.5% drop in A1c ~0.5% drop in A1c Blood sugar, insulin, food, activity, stress Charting Improves Control

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

45 Analyze Carb Boluses 1.Count carbs 2.Give carb bolus 3.Eat 4.Record BGs 5.Analyze BGs 6.Balance better next time

46 Match Your Carbs With Boluses Accounts for HALF the days control! Accounts for HALF the days control! Keeps blood sugar normal after meals Keeps blood sugar normal after meals Requires accurate carb counting and an accurate carb factor Requires accurate carb counting and an accurate carb factor 500 Rule provides a close estimate of carb factor if the TDD is accurate 500 Rule provides a close estimate of carb factor if the TDD is accurate

47 500 Rule To Find Carb Factor Gives grams of carb covered by one unit of Humalog or Novolog Gives grams of carb covered by one unit of Humalog or Novolog 500 / TDD = grams of carb per unit of insulin 500 / TDD = grams of carb per unit of insulin Example: Example: Persons TDD = 50 units Persons TDD = 50 units 500/50 = 10 grams of carb covered by 1 unit of Humalog or Novolog 500/50 = 10 grams of carb covered by 1 unit of Humalog or Novolog Postmeal readings stay normal! Postmeal readings stay normal!

48 2000 Rule To Find Correction Factor Gives how far your blood glucose is likely to fall per unit of insulin over 5 hours 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 2000 / TDD = # mg/dl your BG will fall per unitExample: Persons TDD = 25 units Persons TDD = 25 units 2000/25 = an 80 mg/dl drop per unit of H or Nov 2000/25 = an 80 mg/dl drop per unit of H or Nov Adapted from 1500 Rule by Dr. Paul Davidson, Atlanta, GA

49 2000 Rule 1600, 1800, 2000, or 2200 may be divided by TDD to get point drop per unit 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 Data storage and download Easy recording of BGs, insulin, carbs, activity Easy recording of BGs, insulin, carbs, activity Automatic carb counting Automatic carb counting Pattern recognition Pattern recognition Insulin dose guidance Insulin dose guidance Data analysis to improve control Data analysis to improve control Feedback that encourages use Feedback that encourages use

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

52 Troubleshooting

53 Most Pump Problems Occur In First week First week First month First month First 6 months First 6 months Problems are most likely when unexpected or inconvenient

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

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

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

57 Will Your Pump Alarm? Low battery Mechanical problem Empty reservoir Clog Forgotten bolus LeakBleeding Bad programming Dislodged infusion set Yes No

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

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

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

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 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 Loss of basal insulin delivery for several hours Insulin resistance from length of hyperglycemia Insulin resistance from length of hyperglycemia Insulin resistance from presence of ketones Insulin resistance from presence of ketones

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

63 Questions ???


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