1. Advanced Pump Management
Gary Scheiner MS, CDE
Integrated Diabetes Services
333 E. Lancaster Ave., Suite 204
Wynnewood, PA
(877)
(610)

2. Advanced Pump Management
Basal Insulin Regulation
Bolus Regulation
Physical Activity Adjustment
DKA Prevention
Temporary Basal Rates
Prolonged Boluses
Alternate Basal Patterns

3. Basal Insulin Regulation
Basal Insulin’s One And Only Job Is To Hold Blood Glucose Levels Steady In the Absence of Confounding Influences*
* Food, Exercise, Bolus Insulin, Unusual Hormonal Conditions (illness, rebounds, menstruation)

4. Basal Insulin Regulation
Conditions for Testing Basal Rates:
No food or bolus for at least 4 hrs prior
Last meal/snack low in fat
No food or bolus during test phase (water/diet drinks OK)
BG above 80, below 250 throughout
No lows for previous 12 hrs
Stay connected, no stopping/suspending
Exercise OK up until test phase (if usually performed)
No heavy activity during test phase
Do not run test if sick or just prior to/start of period

5. Basal Insulin Regulation
Sample Basal Testing Schedule
Test
Last Meal / Bolus By
Check BG at
May Eat / Bolus Again at
Overnight
6pm (skip night snack)
10pm, 1am, 4am, 7am
7am
Morning
3am (skip breakfast)
7am, 9am, 11am, 12noon
12 noon
Afternoon
8am (skip lunch)
12 noon, 2pm, 4pm, 5pm
5pm
Evening
1pm (have late dinner)
5pm, 7pm, 9pm, 10pm
10pm

6. Basal Insulin Regulation
Average basal profiles*
* Diabetes Research & Clinical Practice (2005)

7. Basal Insulin Regulation
Example 1: Sara Smiley
Currently:
.30 3am-9am,
.25 9am-3am
Skipped Breakfast
BG results:
6am 109
8am 201
10am 230
12pm 224
Interpretation:
Sharp rise 6am-8am
Modest Rise 8am-10am
Stable 10am-12 noon
Adjustments:
Basal by .1 5a-7a
Basal by .05 7a-9a
Repeat test from 6a-12p

8. Bolus Insulin Regulation
I:C Ratios:
The correct ratio should match pre-meal BG 3-4 hours (not 2!) after eating
I:C Ratio often varies from meal to meal
(bkfst dose > lunch & dinner)

9. Bolus Insulin Regulation
Correction Boluses:
1500-Rule (aggressive)
(Total Daily Ins.)/1500
1800-Rule (conservative)
(Total Daily Ins.)/1800
May vary day vs. night
(nighttime often 50% more than day)

10. Physical Activity Adjustments
Activity Within 2 Hrs After Meal
Activity Before or Between Meals
Short Duration
(<90 Minutes)
Mealtime Bolus
Snack Prior to Activity*
Long Duration (>90 Minutes)
Basal Rate
Snack hourly

11. Physical Activity Adjustments
Meal Bolus
Adjustment*
Low Intensity Cardio  25%
Mod. Intensity Cardio  33%
High Intensity Cardio  50%
Competitive/Anaerobic ???
* If activity is after meal
Basal
Adjustment**
 Basal rate 50%
Start basal reduction 1 hr pre-activity
** For activities lasting > 90 Min.

12. Physical Activity Adjustments
Snacking to prevent low (examples)
Carbohydrate Replacement Per 60 Minutes of Activity
50 lbs
100 lbs
150 lbs
200 lbs
250 lbs
Skating
7-10g
14-20g
20-30g
28-40g
35-50g
Gymnastics
8-12g
17-23g
25-35g
34-46g
42-57g
Soccer
13-17g
27-33g
40-50g
54-66g
67-82g

13. Physical Activity Adjustments
Watch Out for D’OH!
(Delayed Onset Hypoglycemia)
Following high-intensity exercise
Following extended- duration activity
May occur up to 24 hours afterwards
Extra snacks or reduction in basal insulin may be necessary

14. Physical Activity Adjustments
OK To Disconnect Up To 1 Hour w/ Activity

15. Physical Activity Adjustments
Alternatives to Disconnection:
 Wear It! (Sport Pack, Fanny Pack, Backpack Harness)
Re-Connect hourly & bolus 50% of missed basal rate

16. DKA Prevention
Normal Cellular Metabolism  

17. DKA Prevention
Metabolism
With
Insulin
Deficiency   

18. DKA Prevention Progression to DKA Higher B.G. + Dehydration  
Higher B.G.
+ More Ketones
+ Dehydration
 **KETOACIDOSIS**

19. DKA Prevention Causes of insulin deficiency in Pump Therapy   
Malabsorption (site problems)
Insulin Spoilage
Tubing or infusion set clogs
Leaks where the cartridge connects to the tubing
Air pockets in the tubing
Dislodgement of the canula from beneath the skin
Improper or insufficient priming
Extended pump suspension or disconnection

20. DKA Prevention

21. Temporary Basal Rates
Basal Insulin Should Hold BG Steady Under Normal Conditions.
How Often Is Life Under “Normal Conditions”?

22. Temporary Basal Rates High-Fat Food Duration Adjustment Notes 8:00
+60%
Start After Meal

23. Temporary Basal Rates Illness Duration Adjustment Notes 24:00 +80%
Repeat as Needed

24. Temporary Basal Rates Predictable Stress Duration Adjustment Notes
3:00
+80%
Set 1-2 Hours Prior

25. Temporary Basal Rates Extended Inactivity Duration Adjustment Notes
Varies (>3 hrs)
+40%
Great for long trips!

26. Temporary Basal Rates Menstrual Cycles Duration Adjustment Notes 12:00
+50% (pre)
Start at night
-30% (post)

27. Temporary Basal Rates Prolonged Activity Duration Adjustment Notes
Minimum hrs.
-50%
Start 1-2 hours prior

28. Temporary Basal Rates Alcohol Duration Adjustment Notes
2 hrs per drink
-40%
Begin after drinking

29. Prolonged Boluses Description
Normal/Standard Boluses are delivered within a few minutes; peak is approx. 1 hr, duration approx. 4 hours
Prolonged boluses are delivered over a period of a couple of hours; peak is delayed/blunted and duration is extended.

30. Prolonged Boluses Purpose
To do a better job of matching the blood sugar rise caused by slow-digesting foods.

31. Prolonged Boluses Applications Very Large Portions
Low-Glycemic-Index Foods
Meals/Snacks that take a long time to consume

32. Prolonged Boluses
Options for slow-digesting food:
Normal Bolus

33. Prolonged Boluses Square/Extended Bolus
Options for slow-digesting food:
Square/Extended Bolus

34. Prolonged Boluses Dual/Combination Bolus
Options for slow-digesting food:
Dual/Combination Bolus

35. Alternate Basal Patterns
Called Pattern A/B (Medtronic), Prog 2-4 (Animas), Pattern 1-4 (Deltec)
Useful when basal changes are needed for several days (or more) in succession

36. Alternate Basal Patterns
Potential Uses:
Menstrual cycle phases
Extended illness
Recovery from surgery
Periodic use of steroid medications
Seasonal sports
Off-day vs. work/school-day
Extended travel
Climate changes

37. The Ultimate Pump Challenge