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Practical Aspects of Insulin Pumping

Practical Aspects of Insulin Pumping. DeAnn Johnson, RN, BSN, CDE Susie Owen, RN, CDE. Overview:. Evidence for pump therapy Patient selection Dosing Set and site issues Pump attire Sick Days Travel Case study Discussion. BDC results: 1 year pre CSI compared to ea yr thereafter.

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Practical Aspects of Insulin Pumping

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  1. Practical Aspects of Insulin Pumping DeAnn Johnson, RN, BSN, CDE Susie Owen, RN, CDE

  2. Overview: • Evidence for pump therapy • Patient selection • Dosing • Set and site issues • Pump attire • Sick Days • Travel • Case study • Discussion

  3. BDC results:1 year pre CSI compared to ea yr thereafter Chase HP et al, Diabetes Technology& Therapeutics, 9:421,2007

  4. Severe Hypoglycemia and Insulin Pumps (CSII) * ** *Maniatis, Chase, et al. Pediatri,107,351 2001 **Scrimgeour, Chase, et al D T & T 9:421, 2007 (In DCCT: 62per 100 pt. yrs: NEJM, 329, 977, 1993)

  5. Who’s a good candidate?

  6. Essential Criteria for Pump InitiationSurvey of 54 Diabetes Educators * All 54 respondents ranked SMBG as an essential criteria for pump start Lenhard et. al., Infusystems USA 3, 1, 2006

  7. 2007 Consensus Statement on Pump Use in Peds- Patient SelectionEndorsed by the ADA & European Assoc. for the Study of Diabetes • Recurrent severe hypoglycemia • Wide fluctuations in bg levels regardless of A1c • Suboptimal diabetes control • Micro/macro vascular complications • Good control but regimen compromises lifestyle • Infants and neonates • Adolescents with eating disorders • Children and adolescents with pronounced dawn phenomenon • Pregnant adolescents • Ketosis-prone individuals* • Competitive athletes • Children with needle phobia** Battelino,P.M., Rodriguez,H.D., Kauffman, F. Use of insulin pump therapy in the pediatric age-group: consensus statement from the European Society for Paediatric Endocrinology, the Lawson Wilkins Society and the International Society for Pediatric and Adolescent Diabetes, endorsed by the American Diabetes Association and the European Association for the study of Diabetes Care Diabetes Care 2007:30:, 1653-1662 *Blackett PR: Insulin Pump Treatment for Recurrent Ketoacidosis in Adolescence; Diabetes Care;1995;18:891-892. **Maniatis AK et al, Pediatric Diabetes 2001 June;2(2):51-57.

  8. Basal Dosing • Half total daily dose. May decrease by 10-30%. Divide over 24 hours • Convert Lantus or Levemir dose directly into basal • Set pump up in 3 hour increments • Consider dilution to U50 (off label) if using <.05 u/Hr. To order diluent for Humalog 1-800-821-0538, for Novolog 1-800-727-6500 • Keep timing of basal dosing in mind for disconnections • Use alternate increased basals for menses, illness, steroid use and alternate lower basals for high exercise days/nights

  9. Basal Dosing Needs B and C= 708 and 83 primarily pubertal subjects D = 152 subjects F = 117 pre-pubertal subjects From Holterhus PM, et al., Diabetes Care, 2007; 30(3):568-73.

  10. Bolus Dosing • Consider using “Rule of 500 (carbs) & Rule of 1700 (correction)” • Bolus 15-30 minutes prior to meal

  11. Dual Wave Bolusing Mean change in blood glucose levels following four methods of bolus administration. (Chase HP et al. Diab Med 19:317, 2002.)

  12. Use of the Combination or Dual • Useful for all high fat/ high carb meals • May add a unit to total bolus to combat decreased insulin sensitivity • Starting point: Take ½ (50%) of bolus immediately and extend the other half (50%) over the next 2 hours • Check bg at 2,4 and 6 hours • Make adjustments as needed (examples): • > 180* at 2 hrs. =  to 60% Immediate bolus • < 70* at 2 hrs. =  to 40% Immediate bolus • > 180* at 4 hrs. =  to 60% Extended bolus *180mg/dl =10mmol/L

  13. Forgotten Boluses –Increase of a half point in A1c if just 2 boluses missed per week!* • Use of pump alarms • Cell phone alarm • “Food in mouth, hand on pump!” • Upside down plate • Bolus for all carbs (except tx of lows) • Parental review • Evaluate for eating disorder *Chase HP, et al: Pediatrics 113,221,2004

  14. Exercise • Jason Johnson, a pitcher for the Detroit Tigers was diagnosed with Type 1 Diabetes when he was 11. • The MLB approved use of insulin pumps during games in 2004.

  15. Exercise Dosing • Disconnect for duration. Test every 2 hours minimum. May need 50% bolus pre-disconnection for anticipated missed basal + correction and additional corrections throughout activity. • 25-75% decreased temp basal during moderate to intense extended duration activity. May start up to an hour prior. • 25-75% reduction to alternate basal for delayed hypoglycemia during the night starting 2 hours prior to expected drop. • Potential 25-75% decrease to bolus just prior to activity and/or immediately following.

  16. Choosing the Right Site and Set

  17. Pinch test Hypertrophy/lipo-atrophy Curves Disconnection access Diapers Activities Site and Set Considerations

  18. 90 Degree Infusion Sets Cleo Quick set Inset Rapid D Sure T

  19. Angled Infusion sets Inset 30 Comfort Silhouette Tender Omnipod

  20. Minimize Pain and Anxiety • Desensitization:breathing/ distraction/ visualization –bubbles, I Pod • Use of inserter • Use of buttock/hip • Parent wears at saline start • Respect rituals Maniatis AK et al, Pediatric Diabetes 2001 June;2(2):51-57.

  21. Numbing agents • ice – teething rings, cold stones • Gigi Waxing Spray • L-M-X4 • Emla crème, generic lidocaine 2.5% /prilocaine 2.5% crème (discs or use with wax paper)

  22. Where to wear? • alana-mireilleapparel.com • Kangaroo Pump Pockets • Mypumpgear.com • Pumpwearinc.com • store.minimed.com

  23. Wearing the Pump

  24. Cell Phone/PDA Holders as Pump/PDM Holders

  25. Making it Stick (or not) • Antiperspirant • Skin Prep, IV Prep, Bard wipes • Skin Tac / Tac Away • Mastisol / Detachol • IV3000,Tegaderm Polyskin, Water proof sports tape • STR Surgical and Sports Tape Remover

  26. Sick Days • Test blood or urine ketones if >300 or >240 twice • Give a shot and change set if positive • Increase fluid intake • Use of temp basal • Extra tape to site for surgery

  27. Vacations • 10-50% reduction in dosages • Travel letter and current dosing • Take along “loaner pump” and/or basal insulin & syringes • More frequent set changes

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