initiating and adjustment of the insulin pump · • carbohydrate counting • insulin to...

1

Initiating and Adjustment of the Insulin Pump Celia Levesque RN, MSN, CNS-BC, NP-C, CDE, BC-ADM [email protected] Normal Insulin Secretion

mailto:[email protected]

2

Candidate Selection

• Desires insulin pump

• Check BG frequently

• Able to operate pump

• Able to afford pump

• Able to troubleshoot

• Works with medical team

• Hypoglycemia

• Busy schedule

• Athletes

• Dawn phenomenon

• Elevated HbA1c despite best efforts

• Gastroparesis

Pre Pump Education

• Carbohydrate counting

• Insulin to carbohydrate ratio

• Sensitivity factor

• Sick day management

• Prevention of DKA / ketone testing

• Hypoglycemia treatment

• BG testing / BG goals / record keeping Calculating insulin pump doses

1. Calculate the total pump total daily dose (TDD) 2. Calculate a single basal rate 3. Calculate the insulin to carb ratio 4. Calculate the correction factor 5. Choose a target BG range 6. Choose the active insulin time

Calculating Total Pump Total Daily Dose (TDD) Method 1: Pre-pump TDD x 0.75 Method 2: Weight: kg x 0.5 OR lb. x 0.23 Clinical considerations

• Average values from methods 1 & 2

• Frequent hypoglycemia: start at lower dose

• Hyperglycemia, HbA1c, preg: start higher dose

Grunberger, G, Abelseth, J., Bailey, T, et. al. Consensus statement by the American Association of

Clinical Endocrinologist/American College of Endocrinology Insulin Pump Management task force.

Endocrine Practice. 2014;20(5):463-489.

Example: Calculate Pump TDD Average total daily dose = 50 units, Weight = 100 kg

• Method 1: 50 units x 0.75 = 37.5

• Method 2: 100 x 0.5 = 50

• Average: 37.5 + 50 ÷ 2 = 43.75

3

Initial Single Basal Rate (50% TDD) Pump total daily dose x 0.5 ÷ 24 hrs = basal Or Pump total daily dose ÷ 48 = basal rate

Example:

• TDD = 30 units

• 30 x 0.5 = 15

• 15 ÷ 24 hours = 0.625 units per hour

Carbohydrate Ratio 450 ÷ TDD before pump

Alternate methods:

6 x wt. in kg ÷ TDD or 2.8 x wt. in lb. ÷ TDD Fixed Meal Bolus = TDD x 0.5 ÷ 3 equal meals Continue existing CR from MDI regimen

Example: Total dose before pump = 45 units

• 450 ÷ 45 = 10

• 1 unit for every 10 grams of carbohydrate

Sensitivity/Correction Factor

1700 ÷ Pump TDD Example: Total pump dose = 85 units

• 1700 ÷ 85 = 20

• 1 unit will decrease the BG by ~ 20 mg/dL

4

Calculate the following: Sally is a 12-year-old female with type 1 diabetes since age 4 and no other health issues. She is very active and is a cheerleader at school. She has never had severe hypoglycemia. She uses Humalog for her meals and correction of hyperglycemia. Her most recent HbA1c is 8.2%. Her weight is 41.5 kg and her pre pump total daily dose is 29 units Pump Total Daily Dose (PTDD):

• Method 1: _______ units TDD x 0.75 = __________

• Method 2: _______ kg x 0.5 =__________

• Average: method 1 __________ + __________ ÷ 2 = __________ Insulin to Carbohydrate ratio:

• 450 ÷ __________ pre pump TDD = __________ Sensitivity Factor based on Average pump total daily dose

• 1700 ÷ __________ pre pump total daily dose = __________ Single basal rate based on average total pump dose

• __________ pump total daily dose ÷ 2 ÷ 24 hours = __________ units per hour

What target BG would you select?

What active insulin time would you select?

5

Calculate the following: Mr Washington is a 56-year-old male with type 1 diabetes for 35 years. He has hypoglycemia unawareness with 3 episodes of severe hypoglycemia. He has widely fluctuating BG levels, a history of stable stage 3 chronic kidney disease and stable treated proliferative diabetic retinopathy. He exercises most days of the week. His most recent HbA1c is 7.4%. His weight is 90 kg and his pre pump total daily dose is 72 units per day. Pump Total Daily Dose (PTDD):


• Method 2: _______ kg x 0.5 =__________







6

Calculate the following: Ms. Thompson is a 24-year-old female with type 2 diabetes since age 16. She does not have any diabetes related long-term complications. She is not active. She weights 120 kg and her pre pump total daily dose is 140 units. Pump Total Daily Dose (PTDD):


• Method 2: _______ kg x 0.5 =__________







7

Continuous Glucose Monitoring

• Measures interstitial fluid glucose

• Subcutaneous catheter attached to a transmitter

• The receiver displays a new result every 5 minutes o Pump screen o Stand alone receiver o Phone

Interstitial Fluid Glucose

• Does not always match blood glucose

• Interstitial glucose lags behind blood glucose

• The faster the change in BG, the greater the difference between IFG and BG What happens between finger sticks?

Benefits of CGM

• Reduce risk for hypoglycemia secondary to alarms

• Reduce risk for extreme hyperglycemia secondary to alarms

• Reduce risk for wide BG fluctuations

• Behavior modification / learning

8

INSULIN PUMP FINE TUNING

The insulin pump is a great tool to manage diabetes in those requiring insulin. However, from time to

time, the rates may need to be adjusted.

The purpose of the basal rate is to keep the blood sugar within target range when NOT eating. The

purpose of the meal bolus is to keep the blood sugar within target after eating food. The purpose of

the correction/sensitivity factor is to correct high blood sugar back to target.

None of the following tests should be done when you are sick, or when other unusual circumstances

are going on. You should perform these tests ONLY with the knowledge and guidance of your

healthcare provider.

When testing BASAL RATES, one should not eat or exercise during the test. Do not eat a high fat

meal just prior to starting the test. Start the test ONLY if the starting blood sugar is within your target

range. The goal of the basal rate is to keep your blood sugar from rising or falling by more than 30

mg/dL from your target.

When testing MEAL BOLUSES, only start the test when your blood sugar is within target before the

meal you are going to test. Eat a meal with a known number of grams of carbohydrate. Do not eat

mixed meals like pizza or casseroles. The goal is to have your blood sugar rise no more than 50

mg/dL.

When testing SENSITIVITY/CORRECTION BOLUSES, only start the test when your blood sugar is

at least 50 mg/dL above your target. Perform the test when you have not taken a bolus or eaten any

food for 4 hours and you can go without eating for an additional 4 hours. The goal is to have your

ending blood sugar within 30 mg/dL of your target.

9

TESTING OVERNIGHT BASAL RATE

INSTRUCTIONS Test 1 Test 2 Test 3

BEFORE DINNER BLOOD SUGAR

Within target? Continue the test.

2 HOURS AFTER DINNER

Over 50 mg/dl (2.8 mmol/L) higher than pre-dinner glucose? Stop

test. Start test again tomorrow night with an adjusted dinner bolus.

BEDTIME

Under 100 mg/dl (5.6 mmol/L)? Stop the test and eat a snack. Start

test again tomorrow night with an adjusted meal bolus. Over 250

mg/dl (13.9 mmol/L)? Stop test. Follow high glucose guidelines. Start

test again tomorrow with adjusted basal rate.

OVERNIGHT (half way through your sleep cycle)

Under 90 mg/dl (5 mmol/L)? Stop test and eat a snack. Start test

again tomorrow night with an adjusted basal rate. Over 250 mg/dl

(13.9 mmol/L)? Stop test. Follow high glucose guidelines. Start test

again tomorrow night with adjusted basal rate.

BREAKFAST TIME (Do not eat breakfast!)

Under 70 mg/dl (3.9 mmol/L)? Treat low and stop test. Start test again

tomorrow night with an adjusted basal rate. Over 250 mg/dl (13.9

mmol/L)? Stop test. Follow high glucose guidelines. Start test again

tomorrow night with an adjusted basal rate.

2 HOURS AFTER BREAKFAST TIME

Same instructions as breakfast time.

4 HOURS AFTER BREAKFAST TIME

Same instructions as breakfast time.

BEFORE LUNCH (Eat Lunch!)

Take lunch bolus and any necessary correction bolus. Call your

healthcare provider for your basal rate adjustment.

10

TESTING DAYTIME BASAL RATE


BEFORE BREAKFAST


2 HOURS AFTER BREAKFAST

Over 50 mg/dl (2.8 mmol/L) higher than pre-breakfast glucose? Stop

test. Start test again tomorrow with an adjusted breakfast bolus.

LUNCHTIME (Do not eat lunch!)


tomorrow with an adjusted basal rate. Over 250 mg/dl (13.9 mmol/L)?

Stop test. Follow high glucose guidelines. Start test again tomorrow

with an adjusted basal rate.

2 HOURS AFTER LUNCHTIME

Same instructions as lunchtime.





DINNERTIME (Eat Dinner!)

Take dinner bolus and any necessary correction bolus. Call your

healthcare provider for your basal rate adjustment.

BEFORE BREAKFAST


11

TESTING EVENING BASAL RATES


BEFORE LUNCH


2 HOURS AFTER LUNCH

Over 50 mg/dl (2.8 mmol/L) higher than pre-lunch glucose? Stop test.

Start test again tomorrow with an adjusted lunch bolus.

DINNERTIME (Do not eat dinner!)


tomorrow with an adjusted basal rate. Over 250 mg/dl (13.9 mmol/L)?

Stop test. Follow high glucose guidelines. Start test again tomorrow

with an adjusted basal rate.

2 HOURS AFTER DINNERTIME

Same instructions as dinnertime.





BEDTIME

If you would like a snack, take a snack bolus and any necessary

correction bolus. Call your healthcare provider for your basal rate

adjustment.

BEFORE LUNCH


12

TESTING MEAL BOLUS


PRE-MEAL

Count carbohydrate and take meal bolus

Carbohydrate =______ grams

Meal bolus =______ units

(1 unit/________ grams of CHO)

2 HOURS POST MEAL

3 HOURS POST MEAL

4 HOURS POST MEAL

TESTING CORRECTION FACTOR


BEGINNING

Take correction bolus now =______ units

1.0 unit for ________ mg/dl (mmol/L)

1 HOUR

2 HOUR

3 HOUR

13

Overnight Basal Test

Morning Basal Test

14

Bolus Test

Bolus Test

15

Correction Factor Test

Correction Factor Test

16

Troubleshooting Hyperglycemia Insulin

• Loss of potency

• Wrong insulin in pump Infusion set

• Bent catheter

• Air in tubing

• Infusion site problem

Insulin pump

• Programming error

• Pump malfunction Behavior

• Missed bolus

• Bloused after eating

• Did not correct

• Miscount CH

Blood Glucose Over 250 mg/dL

• Take correction bolus via pump. Recheck BG in 1 hour. If BG decreasing, no further action needed

• If BG not decreasing then check ketones and….

Negative Ketones Positive ketones

1. Inject insulin using a syringe according to correction factor

2. Drink 8 oz sugar-free fluid every 30 min 3. Recheck BG in 1 hour 4. If BG is decreasing change reservoir and

infusion set with fresh insulin and fresh injection site

5. If BG not decreasing with injection, insulin may be bad or dehydration, or illness. Change vials of insulin and inject again and contact provider or go to emergency department. Continue checking BG and ketones every 1 hour and drink sugar-free fluids if possible

1. Contact healthcare provider or go to the nearest emergency department if urine ketones are moderate or large or if the beta-hydroxybutyrate is 0.6 or greater or if you have nausea or vomiting. 2. Do not use the pump while ketones are positive. Only inject insulin with a syringe using the correction factor and target blood glucose. 3. Consume 8 ounces of sugar-free fluid every 30 minutes if possible 4. Continue checking blood glucose and ketones every 1 hour 5. Inject rapid acting insulin every 2-3 hours according to the correction factor and target BG

Beta-hydroxybutyrate

• Precision Xtra ➢ 0.6 – 1.5 = call MD ➢ 1.5 = go to ER

• NovaMax ➢ 0.6 – 1.5 = call MD ➢ 1.5 = go to ER

Supplies Needed

• Insulin

• Syringes

• Pump supplies

• Monitoring supplies

• Hypoglycemia treatment

• Ketone testing: urine/blood

• DM identification

• Glucagon

17

Hypoglycemia

• 20% of T1DM will die from hypoglycemia

• 40% of T1DM will have severe hypo if duration of > 15 years

• Annual rate of severe hypoglycemia requiring emergency medical services: 7.1%

• Mortality rate 1 year after severe hypoglycemia T1 & T2 combined = 17% BG< 70 mg/dl: Type 1 DM vs. Non DM

No Diabetes Type 1 Diabetes / Low C-Peptide

Insulin levels drop Insulin levels high because of injected insulin

Glucagon secreted Glucagon not secreted

Epinephrine release Epinephrine release

Norepinepherine Norepinepherine

Cortisol release Cortisol release

Growth hormone Growth hormone

Neurotransmitters Neurotransmitters

Severe Hypoglycemia Treatment: Glucagon

• Converts glycogen to glucose

• 1 kit = 1 mg raises BG ~ 50 mg/dl

• Given SC, IM, or IV

• 1 mg for child > 4

• ½ mg for child < 4 Mini Dose Glucagon

• Pt unable to swallow CHO but is awake & alert with BG < 80 mg

• 2 “units” for 1 yo

• 1 “unit” per year of age for 2 years & older

• Max 15 “units”

• If not above 80 mg/dL in 30 min, double the dose (max 30) Carbohydrate Counting

Counting CHO: Reading Labels 1. Look at serving size 2. Decide how many servings will be consumed 3. Multiply the servings by the total grams of CHO

18

Effects of CHO, Fat & Protein on BG

19

Total Available Glucose

Nutrient Foods Effect on BG Duration of effect

Carbohydrate 4 cal/gm Simple: fruit juice, jam honey, table sugar, milk, fruit Complex: legumes, grains, beans vegetables peas, cereals, bread, crackers rice, corn potatoes, pasta

100% 5 min – 3 hours

Protein 4 cal/gm Meat, eggs, tofu, cheese, peanut butter

58% 3-6 hours

Fat 9 cal/gm Unsaturated: liquid oils Nuts, some margarines Saturated fats: animal fat, coconut and palm oils

10% 8 hours

Alcohol 7 cal/gm Beer, wine, hard liquors May cause low BG Unpredictable

Adapted from: https://healthonline.washington.edu/document/health_online/pdf/CarbCountingClassALL3_05.pdf Total Available Glucose

https://healthonline.washington.edu/document/health_online/pdf/CarbCountingClassALL3_05.pdf




20

Bolus for Cheeseburger, onion rings, and shake

Adapted from Chase et al: Diabetic Medicine 2002;19:317-321 Exercise

• Most studies show little impact on A1c for T1DM

• Benefits of exercise same as non DM

• If exercise performed within 90 min of a meal, may reduce mealtime bolus

Bolderman, K. M. (2012). Putting your patients on the pump: Initiation and maintenance guidelines

(2nd ed). Alexandria, VA: American Diabetes Association.

Metabolic Response to Light & Moderate Exercise

Normal T1DM

Insulin level decreases Glucagon increases Free fatty acid mobilization increases Restriction of glucose by non exercising skeletal muscle

Insulin level fails to change at the onset of exercise

• Insulin excess: muscle glucose uptake exceeds liver glucose production

• Insulin deficiency: liver glucose production exceeds muscle uptake; FFA release and ketone body formation increase

• Adequate insulin: liver glucose output matches muscle glucose uptake

Bolus Reduction if Exercise within 90 minutes after a meal

Short duration 20-40 minutes

Moderate duration 40-60 minutes

Long duration > 60 minutes

Low intensity - 10% - 20% - 30%

Moderate intensity - 25% - 33% - 50%

High intensity - 33% - 50% - 67%

21

CHO Replacement gm/30 min of Exercise

Weight 50 lb. 23 kg

100 lb. 45 kg

150 lb. 68 kg

200 lb. 91 kg

250 lb. 114 kg

Light activity 3 5 8 10 12

Moderate 5 8 10 12 15

Intense 8 12 18 24 30

Basal Adjustment for Prolonged Activity

• Exercising < 90 minutes: do not change basal

• Exercise > 2 hours o Starting point: decrease basal by 50% o If more intense activity: 70-80% reduction o Start reduction 1-2 hrs before prolonged exercise o Resume full basal rate prior to stopping prolonged exercise o Delayed hypoglycemia may occur after prolonged/intense activity

Exercise Induced Hyperglycemia

• Weight lifting

• Intermittent bursts of activity (softball, golf, martial arts, sprints, judged events

• If hyperglycemia is consistent: o Take extra insulin in preparation: 50% of the amount expected to offset the rise in BG:

give 30-60 min before the expected rise Hyperglycemia Prior to Exercise

• Lack of insulin o If explainable:

▪ hydrate, take 50% of usual correction bolus o If unexplainable:

▪ Check ketones

• If negative: hydrate, take 50% of usual correction bolus, exercise

• If positive: hydrate, administer full correction dose, hyperglycemia protocol, do not exercise

Special Situations

• Kids

• Pregnancy

• Illness

• Menstrual cycle

• Sex

• Travel

• Surgery

• Steroids

• Gastroparesis

Kids & Pumps

• Pump therapy in kids requires commitment and motivation on the part of caregivers

• Children require frequent dose changes

• Tend to need more bolus and less basal insulin compared to adults

• Teens are usually insulin resistant

22

Kids & Pumps: Common problems

• Missed boluses

• Bent catheters

• CHO counting is an adult concept

• Not finishing meal after bolus given

• Unpredictable, impulsive, erratic activity 3-4 year olds

• Can deliver bolus but needs to verify amt before activating

• Use block feature in young kids 7-12 year olds

• Tend to be excited about pump

• Need help deciding on how much to bolus

• Begin to carb count can calculate insulin to carb ratio

• Usually can achieve good control Teens:

• Least reliable group

• Learn quickly

• Preoccupied with many other things, Pump not priority

• Forget to bolus

• Do better on a pump than shots but not as good as younger kids

• NEED PARENTAL INVOLVEMENT Pumps in school

• Train teachers & school nurse

• Care plan for pump issues

• Phone numbers for diabetes care team

• Extra insulin for pump &/or insulin pen for injection

• Pump supplies, numbing cream if used

• Ketone and glucose testing supplies

• Pump batteries

• Insulin syringe and/or pen needles Pumps on the playing field

• If NOT going to detach: o May need to reduce basal rate o May consume CHO if needed

• If going to detach: o Less than 1 hour: no adjustments o Bolus q 1 hr during breaks for missing basal o Small bolus with snacks during breaks

Pregnancy Target BG:

Premeal: 60-99 mg/dL Post meal 1 hr.: < 130 mg/dL

Target HbA1c: < 6% If frequent hypoglycemia, severe hypoglycemia, or hypoglycemia unawareness: customize target BG

23

Evaluate control twice weekly and adjust Pregnancy: BG > 200 follow same rules as non-pregnancy for hyperglycemia treatment but with blood glucose over 200 mg/dL instead of over 250 mg/dL Labor and Delivery

• Follow the hospital protocol

• Hourly blood glucose checks

• BG goal 80-120 mg/dL

• For elective C-section: decrease basal rate by 30% 8 hours before delivery while NPO and if prone to hypoglycemia, reduce 50%

• Active labor: reduce basal rate 30-50%

• Reduced insulin requirements after delivery Illness

• Frequent BG and ketone testing

• Need basal to prevent DKA

• Do not reduce basal unless hypoglycemia

• Basal rates may need to be increased for fever, infection, surgical stress, etc.

• Use hyperglycemia protocol as previous outlined

• If prolonged fasting: sensitivity factor may need to be changed

• Illness

• Increase non caloric fluids

• Need some CHO to prevent ketosis

• If can’t eat solid food: may substitute with liquid CHO

• Teach pt. to call if: o Fever > 100 o Nausea, vomiting, diarrhea > 4 hrs. o Moderate or large urine ketones, or > 0.6 on betahydroxybuterate test

Menstrual Cycle

• Effect on BG varies

• Increased insulin requirements 2-3 days to 1 week before cycle due to changes in estrogen and progesterone causing insulin resistance

• Decreased insulin requirements the day after cycle starts

• May need to adjust both basal and bolus Travel

• If sedentary during the travel: may need temp increase in basal rate 10-20%

• Bring 50% more pump supplies than usually needed for the time away o Spare pump if available o Hypoglycemia treatment including glucagon o Extra insulin, syringes, monitoring supplies

• Know where the nearest pharmacy, and medical care available

• Pack all medical supplies in a carry on bag, Extra glasses if needed

• Insulin stable for 28-42 days at room temperature, Protect insulin from extreme heat

• Low dose x-ray screening and total body scanners: contact pump manufacturer

• Check with airline and TSA for any changes in rules

• When changing time zones:

24

o Keep the pump clock the same at departure and then change it to the new time zone after arriving to the new destination

o If a large time zone change o Change pump clock 2 hours towards the new destination daily until the correct time is

achieved Surgery/Procedure

• What type of surgery?

• How long is the surgery?

• What time will the surgery start?

• How long will the patient fast?

• What kind of diet will the patient have after surgery?

• Will the patient be receiving IV dextrose?

• What type of anesthesia?

• Can the patient skip a meal without hypoglycemia?

• Does the patient have a history of severe hypoglycemia?

• Does the patient have hypoglycemia unawareness? General Anesthesia

• Neuroendocrine stress response o Epinephrine o Glucagon o Cortisol o Growth hormone

• Inflammatory cytokines o interleukin-6 o tumor necrosis factor-alpha

Metabolic Abnormalities from Surgery/Anesthesia

• Insulin resistance

• Decreased peripheral glucose utilization

• Impaired insulin secretion

• Increased lipolysis and protein catabolism

• Hyperglycemia

• In some cases: ketosis

• General anesthesia is associated with larger metabolic abnormalities as compared to epidural anesthesia

Glycemic Goals for Surgery

• Avoidance of marked hyperglycemia

• Avoidance of hypoglycemia

• Maintenance of fluid and electrolyte balance

• Prevention of ketoacidosis Options:

• Take pump off and replace basal insulin: o 1 injection of basal prior to surgery o ½ dose prior to surgery, ½ dose 12 hrs. later

25

o Patient given corrections for hyperglycemia using Regular or Rapid-acting analog insulin

• Leave pump on at full basal rate o Patient given corrections for hyperglycemia using Regular or Rapid-acting analog

insulin

• Leave pump on at reduced basal rate ▪ Patient given corrections for hyperglycemia using Regular or Rapid-acting analog

insulin Gastroparesis

• Stomach emptying is variable

• Many have gastroparesis without sx

• Use special bolus features as needed to match stomach emptying

• Generally: gastroparesis diet is low fat, low fiber Steroids

Steroid Equivalent Onset Duration

Betamethasone 20 0.6 mg Rapid

Cortisone 1 25 mg Slow 30-36 h

Dexamethasone 20 20-30 x > than HC 5-7 x > Prednisone

0.75 mg Rapid 72 hours

HC acetate 1 20 mg Slow Long

HC sodium phosphate 1 20 mg Rapid Short

HC sodium succinate 1 20 mg Rapid Short

MP 5 4 mg Rapid 30-36 h

Prednisolone 4 5 mg Rapid 18-36 h

Prednisone 4 5 mg Rapid

• Low dose steroids: less than equivalent of Dexamethasone 40 milligrams o 40% basal o 60% bolus

• High dose steroids: equivalent of Dexamethasone 40 milligrams or higher o 25% basal o 75% bolus o Steroids

• Total initial insulin dose: o Low dose steroids: start at 0.6-0.8 units/kg o High dose steroids: start at:

▪ 0.9 units/kg if on metformin ▪ 1.2 units/kg if not on metformin

initiating and adjustment of the insulin pump · • carbohydrate counting • insulin to...

Documents