Adjusting Insulin Pump Settings - infusemeddev.cominfusemeddev.com/medtronic/ADVANCE...
Transcript of Adjusting Insulin Pump Settings - infusemeddev.cominfusemeddev.com/medtronic/ADVANCE...
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Objective
Introduce principles, tools and methodology for adjusting insulin pump settings
Key Points• Adjusting Pump Settings is a systematic, logical process• Basic Principles - Similar to adjustment decisions in other regimens
– Basal Rate (Basal), – Carbohydrate Ratio (Bolus), – Insulin Sensitivity Factor (Correction)
• Medtronic Tools – “Pumping Protocol” by Dr. Bruce Bode– Logbook Practice Sheets– CareLink Therapy Management Software– Adjustment & Fine-tuning Workshop
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Current Data Collection Methodology
Monday87-218-152- 66Tuesday 57--132-66
Wednesday53-308-155Thursday
3am: 55 / 200 /90
Saturday70-200
Friday73-208-105
“Use Whatever You Can Get!”
Logbooks / Logsheets Notepads, sticky notes, napkins, envelopes
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Adjustment Phase – Patient Guidelines
• Check BGs Regularly– Pre-meal, 2-hrs post-meal, bedtime and mid-sleep
• Eat low-fat meals (with known carb content)– Avoid snacks (during adjustment phase)
• Use Bolus Wizard Calculator– Calculates Bolus– Tracks Active Insulin– Captures Data
• Records time and amount of bolus, carb intake, etc.
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Adjustment Phase – Clinician Guidelines
• Use standardized log-sheets or specified reports• Be systematic and analytical
– Divide days into segments • (bedtime to 3am; 3am to 7am; pre- to post meal; post- to pre-meal)
• Evaluate BGs every 2-3 days– Upload pump -- Fax log-sheets -- Office visit
• Evaluate based on: cause-and-effect and repeated patterns
• Make one (no more than two) adjustments at a time
• Confirm Setting Adjustments – Review BGs 2-3 days post adjustment
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Primary Factors
• Basal Rates
• Carbohydrate Ratios
• Insulin Sensitivity Factors
Adjustment Parameters
Secondary Factors
• Target Ranges
• Active Insulin Time
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Blood Glucose Flow Sheet
BG
BedtimePost-DinnerPre-DinnerPost-LunchPre-LunchPost-BrkfstPre-BrkfstNocturnalDate:Time
Total Bolus
Post-Brkfst
Corr. Bolus
Total Bolus
BedtimePost-DinnerPre-DinnerPost-LunchPre-LunchPre-BrkfstNocturnalDate:Time
Carb GramsBG
Food Bolus
Carb Grams
Corr. BolusFood BolusCarb GramsBGTime
BedtimePost-DinnerPre-DinnerPost-LunchPre-LunchPost-BrkfstPre-BrkfstNocturnalDate:
Time RateBasal Rate: 1) 12 am o.60 u / hr___
2) ______ ___________3) ______ ___________
Patient:____________________________________ DOB:______________________Date:______________________ Phone: (H) _________________________________ (Wk) ______________________ /__________________________
Carb Ratio: (B) ________ (L)_________ (D)____________
Sensitivity Factor: = ___________mg/dL per 1 unit of insulin
BG Target Ranges: Daytime: ______mg/dL – _________mg/dL
Nighttime:_______mg/dl – ________mg/dL
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Blood Glucose Flow Sheet
BG
BedtimePost-DinnerPre-DinnerPost-LunchPre-LunchPost-BrkfstPre-BrkfstNocturnalDate:Time
Total Bolus
Post-Brkfst
Corr. Bolus
Total Bolus
BedtimePost-DinnerPre-DinnerPost-LunchPre-LunchPre-BrkfstNocturnalDate:Time
Carb GramsBG
Food Bolus
Carb Grams
Corr. BolusFood BolusCarb GramsBGTime
BedtimePost-DinnerPre-DinnerPost-LunchPre-LunchPost-BrkfstPre-BrkfstNocturnalDate:
Patient:____________________________________ DOB:______________________Date:______________________ Phone: (H) _________________________________ (Wk) ______________________ /__________________________
Look across to review the “Cause & Effect” of the day’s events
Look down
forrepeated
“Patterns”
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Focus on Overnight Basal Rate First
• Eliminates risk of nocturnal hypoglycemia– Allows patient to sleep through the night
• Patient begins day with normal BG– Allows for better evaluation of daytime basal rates
and carbohydrate ratios when patient is not correcting high or low fasting BGs
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Overnight Basal Rate
NOTE: BG should always be >100mg/dL at bedtimeNOTE: BG should always be >100mg/dL at bedtime
• Divide night into time periods– (bedtime to mid-sleep) (mid-sleep to wake-up)
• Evaluate overnight glucose control by comparing BG values across time periods
• Adjust basal rate based on rise or fall pattern Adjustment Guidelines
Goal: BG stays within target range through the night
– No more than 30mg/dL change from bedtime to morning
• If BG rises >30 mg/dL: Increase basal rate by 10%-20%
• If BG falls >30 mg/dL: Decrease basal rate by 10%-20%
• Start time of adjusted basal rate should begin 2-3 hours prior to the observed rise or fall in glucose
Adjustment GuidelinesGoal: BG stays within target range through the night
– No more than 30mg/dL change from bedtime to morning
• If BG rises >30 mg/dL: Increase basal rate by 10%-20%
• If BG falls >30 mg/dL: Decrease basal rate by 10%-20%
• Start time of adjusted basal rate should begin 2-3 hours prior to the observed rise or fall in glucose
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Total BolusCorr. BolusFood BolusCarb GramsBGTime
Post-BrkfstPre-BrkfstNocturnalBedtimeDate:
121 117 92
• Maintain stable BG during fasting state
• Allow patients to postpone / skip meals / sleep late
Properly Set Basal Rates: 0.6
0.60.6
0.6
0.60.60.60.6
0.6
0.60.6
0.6Verifying Overnight: Basal Rates
Basal Rate: 12am @ 0.6 u
11:00 pm 3:00 am 6:30 am
Stable Stable
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Corr. Bolus
Carb Grams
Food Bolus
1221388412882135180108BG
BedtimePost-DinnerPre-DinnerPost-LunchPre-LunchPost-BrkfstPre-BrkfstNocturnalDate:11:008:306:002:2012:008:456:303:00Time
Total Bolus
Post-Brkfst
Corr. Bolus
Total Bolus
BedtimePost-DinnerPre-DinnerPost-LunchPre-LunchPre-BrkfstNocturnalDate:11:008:306:002:2012:008:456:303:00Time
Carb Grams1211409013389127192122BG
Food Bolus
Total Bolus
Corr. BolusFood BolusCarb Grams
1181428012885130188118BG11:008:306:002:2012:008:456:303:00Time
BedtimePost-DinnerPre-DinnerPost-LunchPre-LunchPost-BrkfstPre-BrkfstNocturnalDate:
---
---
---
---
123
11:05
Bedtime
Basal Rate: 12am 0.6
Stable Rising
Basal Rate: 12am 0.63am 0.7 7am 0.6
Overnight Basal Rates
Stable Rising
Stable Rising
Consistent Rise >30mg/dL over 3 days– Dawn Phenomenon
What would you adjust?
Bedtime3am 3amMorning
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Insulin to Carbohydrate Ratio Adjustments
Compare the pre-meal BG to the 2-hr post-meal BG
Adjustment Guidelines:
• If the 2-hour post-meal BG is > 60mg/dL above pre-meal– Decrease the carbohydrate ratio by 10-20%
• If the 2-hour post-meal BG is <30mg/dL above pre-meal– Increase the carbohydrate ratio by 10-20%
Adjustment Guidelines:
• If the 2-hour post-meal BG is > 60mg/dL above pre-meal– Decrease the carbohydrate ratio by 10-20%
• If the 2-hour post-meal BG is <30mg/dL above pre-meal– Increase the carbohydrate ratio by 10-20%
GOAL
Post-meal BG should be ~ 30–60mg/dL higher than pre-meal BG
GOAL
Post-meal BG should be ~ 30–60mg/dL higher than pre-meal BG
14128144911228521292112BG
BedtimePost-DinnerPre-DinnerPost-LunchPre-LunchPost-BrkfstPre-BrkfstNocturnalDate:11:308:206:002:4012:309:457:303:15Time
Total Bolus
Post-Brkfst
----0.3-----0.10.7u-0.2Corr. Bolus
Total Bolus
BedtimePost-DinnerPre-DinnerPost-LunchPre-LunchPre-BrkfstNocturnalDate:10:458:456:302:3012:159:207:103:05Time
756045Carb Grams125132851339220590115BG
5.0u6.03.0Food Bolus
Carb Grams
-------- 0.2----0.2+ 0.5- 0.3---Corr. Bolus------7.5---6.5---6.0---Food Bolus------75---65---60---Carb Grams
120130871259019488110BG11:008:306:002:2012:009:157:003:00Time
BedtimePost-DinnerPre-DinnerPost-LunchPre-LunchPost-BrkfstPre-BrkfstNocturnalDate:
Carb Ratio: 1:10Basal Rates: 12am 0.63am 0.77am 0.6
Rising
Carb Ratio: (B) 1:8 (L) 1:10 (D) 1:10
Carbohydrate Ratios
Stable Stable
Pre-meal to Post-meal
Rising
Rising
Stable Stable
Stable Stable
What would you adjust?
Consistently high post (B) : Within normal ranges post (L) & (D)
Lowering the carb ratio increases the meal bolus. Ex: 60 grams 1:10 = 6.0 u 1:8 = 7.5u
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OvernightBreakfast DinnerLunch
Logbook Report
Red = Lows
Gold = Highs
Look across to review the “Cause & Effect” of the day’s events
Look down
forrepeated
“Patterns”
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Carb Ratio: 1:10
Rising
Carb Ratio: (B) 1:8 (L) 1:10 (D) 1:10
Overnight Basal Rate Carbohydrate Ratios
Stable
What would you adjust?
Consistently high post (B) : Within normal ranges post (L) & (D)
Overnight Breakfast Lunch
Stable
Logbook Report
Stable Rising Stable
Stable Rising Stable
Lowering the carb ratio increases the meal bolus. Ex: 60 grams 1:10 = 6.0 u 1:8 = 7.5u
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Adjusting Pump Settings: A Logical Systematic Process
1) Gather Information
2) Interpret and Analyze Data
3) Adjust VariablesTraditional information•Log-book•Verbal communication• Meter & Pump downloads
Medtronic Technologies • CareLink Software
• Personal (web-based)• Professional
• Solutions Software
Primary Factors•Basal rate•Carbohydrate Ratio•Sensitivity Factor
Secondary Factors •BG Target Range•Active Insulin Time
•Traditional Meter BG Interpretation• Diabetes Therapy Management Software Analysis
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