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Pumping How Do I Start? John Walsh, P.A.

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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: 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 ???

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