Presentation on theme: "Pumping How Do I Start? John Walsh, P.A."— Presentation transcript:
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 setWhat is needed to startImportance of dataSite preparationTroubleshootingFormulas that helpSmart features
3 Where Pumps BeganStarted ~1978 with conversion of portable chemotherapy pumps to delivery of insulinThe Autosyringe AS2C and Harvard Apparatus Mill Hill Infuser were firstSingle basal, no memory50 ml syringe on pump exteriorRequired dilution of insulin to U-36 or U-181976 Biostator (top) and 1978 Autosyringe AS2C –>
5 Advantages Flexibility in meal timing & size Eat when you want to Beginning PumpingAdvantagesFlexibility in meal timing & sizeEat when you want toFaster adjustment of insulin for exerciseFamily activities are no longer tied to one person’s needsEasier handling of illness, travel, or campingA 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 dayOrder of variablility: NPH > Lente > Lantus > DetemirA pump has less variable insulin delivery at 3%
7 Advantages Precise doses, as small as 0.025 u, can be given Manages the Dawn PhenomenonImproves control during growth spurts and adolescenceReminders
9 Why Choose A Pump? A freer lifestyle Easier dose determinations Improved blood sugarsFlexibility in meal timing and sizeAbility to exercise without losing controlPeace of mind
10 When To Consider A Pump More than 3 injections per day Beginning PumpingWhen To Consider A PumpMore than 3 injections per dayTired of multiple injectionsFrequent or severe hypoglycemiaHypoglycemia unawarenessElevated A1cDKA or ER/hospital admissionStrong Dawn PhenomenonRequire small, precise dosesLess risk of complicationsInsulin 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 A1cSlightly less insulin use per dayConMore DKAMore severe hypoglycemiaA1c levels and frequency of DKA & hypoglycemia are similar to ICT
12 What It Takes To Succeed Beginning PumpingWhat It Takes To SucceedA personal desire for better controlWilling to adjust insulin doses to carb count, test results, and activityWilling to monitor at least 4 times a dayWilling to keep an accurate record of BGs, boluses, and carb countsCommitted to solve problems and adapt lifestyle as neededAn 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 10Family support is essential: an adult who can go to school, etc.Communication with a health care team that is committed to pumpsAdequate insurance and financial resourcesAssistance and support from teachers, friends, babysitters, grandparents, siblings
14 Features For Infants & Toddlers Little ones are ideal pump candidates if the parents areDelay or split boluses for fussy eatersSmall, user-friendly pumps offer precise dosing (0.05, 0.025, or 0.01 unit increments)Lock outWorn between shoulder bladesIf 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 snacksTDD and bolus history can be checked to ensure consistent dosingFaster adjustment of basals and boluses for changes in activity, etc
16 Special Teen Concerns Dating Wearing, sharing Alcohol Eating disorders Fast foodsFabricationSleeping-in
17 Learn how to adjust your basals and boluses for an excellent A1c! Personal EffortThose 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 recordsConsider your (and your child’s) motivationPeer group, acceptance issues, family supportLook at available pumpsWhich pump(s) does your insurance cover?Talk with your doctor about a prescriptionVisit 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 patternsWhen to increase and decrease basals and bolusesHow to adjust for high GI foods, extra activity
21 Pump Companies Who sell or plan to sell pumps in the US: Animas R1200 Dana Diabecare IIIDeltec CozmoMedtronic ParadigmNipro AmigoRoche/DisetronicVisit
22 Things To Consider Look, feel, color Features: reminders, child block, waterproofingSize of basal and bolus incrementsInfusion set choicesSafety and reliabilityCustomer supportHistoryEase of data analysisAdd-ons: meters, covers, cases
23 Today’s Smart PumpsEasy dose calculations with Carb Factor and Correction FactorPrecise insulin dosing (0.05 units or better) to allow basal rates to be set up for Dawn Phenomenon, etc.Tracks BOB to avoid insulin stackingReminders
24 Today’s PumpsWhen 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…..
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 failuresInsertion site is visibleLonger is more secureAdjust angle to reach fatMetal needles (Rapid-D or bent needle)As comfortable and often more reliableVery short, multi-needle infusion sets expected soon
27 Infusion Sets And Inserters Disetronic Rapid-DSmith’s Medical CleoAnimas InsetMedtronic Sil-serterQuik-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-SerterAdhesive: IV-3000, Hypafix, TegadermStickies: Skin Tac-H, Skin PrepTape: Micropore, Durapore, Band-Aid Blister Relief (wicking)Sweating aid: Mastisol Spray (Detachol for removal), Skin Tac, Tincture of Benzoin, Skin PrepAdhesive removal: Uni-Solve, Allkare
29 School Supplies Meter, lancets, test strips Glucagon, glucose tablets, or crackers for lowsSpare insulin, syringes or insulin penSpare infusion set and pump batteriesKetostix or Precision Xtra to test for ketonesInformation card with insulin-to-carb ratio, formula for correctionsTelephone numbers of parents, health care providers, and pump manufacturer's help line
31 Starting On A Pump Everyone is nervous Read, read, read Beginning PumpingStarting On A PumpEveryone is nervousRead, read, readPumping Insulin, Kids Insulin Pumps And You (Animas), etc, etcDo lots of recording before and after startStart to play with pump as soon as it arrivesSaline practice helpsGet telephone contacts: MD, CDE, pump company, pump rep, other parentsNervousness 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 diabetesA pump is a tool, not a cureTake a bolus for every biteChange site as directedLook for a solution for every problemWrite down a reason for every low and highTest often
33 J Walsh and R Roberts: Pumping Insulin, 2005 John’s Pump RulesTotal Daily Dose = weight in lbs / 4Basal Dose = 50% to 60% of TDDCarb Factor = 500 / TDDCorrection Factor = 2000 / TDDBG target = 90 to 120 mg/dlBasal target = +/- 30 mg/dlBOB = 20% per hourCorrection boluses = < 8% of TDDJ 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 PumpingCarb CountingAllows precise matching of carbs with bolusesGlycemic index, saturated fat, and high protein all play a role, but grams of carb is what controls the blood sugar after a mealEasy!A great control tool!
38 Where Carbs Come From fruit/fruit juice breads/bagels cereals crackers Beginning PumpingWhere Carbs Come Fromfruit/fruit juicebreads/bagelscerealscrackersgrainsmuffinsricepotatoes/yamsvegetablesdessert/cookies/cake/pieice cream/frozen dessertsweetened beveragesmilk/yogurt (not cheese)beer/winehoney/syrup/molassesjams/jellys/preserves-ose foods like sucrose (table sugar)1 gram of carbraises the BG4 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 PumpingHow To Count CarbsFood labelsCheck portion sizeBooksDr’s Pocket Guide, Health ChequesA gram scale plus carb factorsCarb factors are available in Pumping Insulin and are built into scales like the Salter computer gram scaleThere are many ways to count carbs.
42 Beginning PumpingBlood 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 PumpingCharting Improves ControlSmart ChartsNeeded to solve problemsBasis for better diabetes health care~0.5% drop in A1cSmart Charts are one of several good charting tools to keep track of why your readings are changing.Blood sugar, insulin, food, activity, stress
45 Analyze Carb Boluses Count carbs Give carb bolus Eat Record BGs Beginning PumpingAnalyze Carb BolusesCount carbsGive carb bolusEatRecord BGsAnalyze BGsBalance better next time
46 Match Your Carbs With Boluses Beginning PumpingMatch Your Carbs With BolusesAccounts for HALF the day’s control!Keeps blood sugar normal after mealsRequires accurate carb counting and an accurate carb factor500 Rule provides a close estimate of carb factor if the TDD is accurateOnce 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 Pumping500 Rule To Find Carb FactorGives grams of carb covered by one unit of Humalog or Novolog500 / TDD = grams of carb per unit of insulinExample:Person’s TDD = 50 units500/50 = 10 grams of carb covered by unit of Humalog or NovologPostmeal 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 Pumping2000 Rule To Find Correction FactorGives how far your blood glucose is likely to fall per unit of insulin over 5 hours2000 / TDD = # mg/dl your BG will fall per unitExample:Person’s TDD = 25 units2000/25 = an 80 mg/dl drop per unit of H or Nov1800 (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 Pumping2000 Rule1600, 1800, 2000, or 2200 may be divided by TDD to get point drop per unitThis 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 PumpingNew DevicesData storage and downloadEasy recording of BGs, insulin, carbs, activityAutomatic carb countingPattern recognitionInsulin dose guidanceData analysis to improve controlFeedback that encourages useThe 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 RocheMedtronic 512 and BD Paradigm LinkAnimas and LifescanDana Diabecare III and Dana meter
53 Most Pump Problems Occur In Beginning PumpingMost Pump Problems Occur InFirst weekFirst monthFirst 6 monthsExperience 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 whenunexpected or inconvenient
54 Occasional Pump Problems Beginning PumpingOccasional Pump ProblemsSetup tipsLeaksO-ringsHubLineClogsSite infections and abscessesAllergiesBleedingonto skininside needleunder skinPump bumpsHypertrophyDKASome frustration at times is normal!
55 Set And Site Issues Dislodged infusion set Tunnelling Infection Beginning PumpingSet And Site IssuesDislodged infusion setTunnellingRapid-D and slanted Teflon sets work better for mobile kidsMetal may be better than teflonInfectionHematoma
56 Site Preparation Prevents pump bumps, infection, and abscess Steps Wash the handsSterilize the skin – IV PrepUse bio-occlusive adhesive – IV 3000Insert the setUse safety tape
57 Will Your Pump Alarm? Low battery Mechanical problem Empty reservoir Beginning PumpingWill Your Pump Alarm?Low batteryMechanical problemEmpty reservoirClogForgotten bolusLeakBleedingBad programmingDislodged infusion setYesNo
58 How To Check Mechanical Problems Beginning PumpingHow To Check Mechanical ProblemsSkin and siteInfusion setConnectionLineHubReservoirPumpCheck fromskin 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 unitClog in line?Alarms? Errors?If no cause is found, replace everything!
60 Go to ER at 1st sign of vomiting! Beginning PumpingCheck Ketones EarlyTest for all BGs over 300Always test when nauseousTest urine with KetodiastixTest blood with Precision Xtra meterEarlier detectionNo need to collect urineKeep currently dated strips availableGo 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 requiredLoss of basal insulin delivery for several hoursInsulin resistance from length of hyperglycemiaInsulin resistance from presence of ketones
62 ConclusionA pump offers the latest technology for precise insulin deliveryRequires commitment and responsibilityBenefits include more flexibility, less hypoglycemia, improved control, and a longer, healthier lifespanMake the commitment and start pumping!