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Advanced Pumping

Advanced Pumping. Objectives:. Identify situations to utilize temporary basal rate in pump therapy patients. Identify examples of when to use combination and e xtended bolus in pump therapy patients.

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Advanced Pumping

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  1. Advanced Pumping

  2. Objectives: • Identify situations to utilize temporary basal rate in pump therapy patients. • Identify examples of when to use combination and extended bolus in pump therapy patients. • Verbalize understanding of the insulin on board feature available in current insulin infusion pumps. • Identify sick day and DKA clinical management guidelines for treatment

  3. Activity • In table teams take 2 minutes to discuss what a temporary basal is? • Come up with 3-5 reasons you might use one and write them on the flip chart.

  4. Temporary Basal Rate • Allows patient to increase or decrease basal rate for a specific period of time based on percent change or units/hr. • Example: • 50% reduction for 2 hours • 20% increase for 4 hours

  5. Clinical Indications for Use of a Temporary Basal Rate • Illness or infection • Change in normal routine • Travel • Work • Medications • Steriods • Stress • Holidays • Exams • Exercise

  6. Temporary Basal Rate and Exercise • With multiple daily injections (MDI), the patient must snack or adjust the rapid or long-acting insulin • With pump therapy, a temporary basal change allows the patient to immediately adjust the amount of insulin being infused

  7. Education for Temporary Basal Use • Check BG frequently to evaluate temporary basal effectiveness • Start conservatively with a decrease or increase of 10-20% • Ability to stop temporary basal at anytime

  8. Evaluating Effectiveness of Temporary Basal Rate • Absence of hypoglycemia/hyperglycemia during exercise • Absence of nocturnal or post-exercise hypoglycemia • Decrease in extra snacking to prevent hypoglycemia • May need to increase or decrease percentage change

  9. Activity • In table teams take 2 minutes to discuss what is an extended bolus? What is a Combo bolus? • Come up with 3-5 reasons you might use would use them.

  10. Extended Bolus • Bolus extended over a designated period of time • Elements of extended bolus • Dosage • Duration Example • 4 units delivered over 2 hours • 6.5 units delivered over 4 hours

  11. Combo Bolus • A portion of bolus is delivered immediately (normal) and a portion is extended over a designated period of time (combo) • Example: 25/75 split using 4 unit bolus would deliver… • Normal (1 unit) • To cover portion of CHO or high BG • Extended (3 units) • To cover high fat bolus or grazing at meals

  12. Clinical Indications for Extended or Combo Bolus • High post-prandial BG’s despite accurate CHO counting • Hypoglycemia immediately following meal • Grazing, extended eating • Buffets • Holiday Meals • Parties • Movies

  13. Clinical Indications for Extended or Combo Bolus • Gastroparesis • Slow eaters, such as young children • Large bolus dosage • May prevent depot of insulin at injection site • Nutrient composition of meal • High fat • Low glycemic foods • High protein

  14. Evaluating the Effectiveness of an Extended or Combo Bolus • Check BG at 2, 4, 6 & 8 hours after meal • If BG remains in target bolus was successful • If BG goes low or rises more than 40-80 mg/dL combo bolus needs to adjusted, consider: • Percent split • Dose • Duration

  15. Foods Effect on Blood Sugar: Protein • Rate of digestion and conversion to glucose depends on state of insulinization and glycemic control • BG effect difficult to predict • Up to 50-60% can be converted to glucose

  16. Foods Effect on Blood Sugar: Fat • Effects on BG • Delayed stomach emptying • Decreased insulin sensitivity • Increased insulin resistance • May last for hours after eating • Minimal fat actually converted to glucose (<10%) • Individual’s response needs to evaluated

  17. Insulin on Board (IOB) • After bolus is delivered, IOB tracks bolus insulin still active • Customizable IOB from 1.5 hrs - 6.5 hrs • May decrease risk of stacking insulin • Potential for less hypoglycemia

  18. What is the effect of illness on BG? • Typically BG is elevated during illness • Liver Glucose release increases • Cells less sensitive to insulin • May have low BG instead • Vomiting • Diarrhea

  19. Activity • In table teams, take 3 minutes to discuss what causes DKA? • What are you currently doing in your practice – to prevent and or treat DKA? • Write current practice guidelines on the flip chart

  20. Causes of Diabetic Ketoacidosis - DKA • Inadequate or missed insulin dose • Illness • Infections • Stress • Infusion set or site issue • Dehydration

  21. Insulin Pumpers and DKA • Insulin Pumpers are at a higher risk for DKA • Only use rapid acting insulin • BG can start to rise within 60-90 minutes of interrupted insulin delivery • Lack of immediate or long-acting insulin

  22. Problem Solving • Check for Ketones – early detection of interrupted insulin delivery • Check tubing for bubbles • Assess infusion site for placement, kinks, disconnection • Cartridge – insulin available, cracks

  23. Prevention of DKA • Check your BG at least 4 times a day • For "unexplained” BG > 250mg/dl or higher -- Check ketones • Take correction bolus by syringe • Change your insulin set and site • Disconnect from the body before priming • Drink plenty of fluids

  24. Activity • In table teams, take 3 minutes to discuss your sick day management plans • List plan on flip chart

  25. Sick Day Plan To Include… • When and who to call • Frequency of BG testing • Frequency of Ketone testing • Blood vs Urine testing • Use of a temp basal, duration of setting • Recommendations for vomiting or diarrhea • What to eat, what if you have given insulin and then vomit. • Possible use of Glucagon for vomiting induced hypoglycemia

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