Advanced Pump Management Gary Scheiner MS, CDE Integrated Diabetes Services 333 E. Lancaster Ave.,...
-
Upload
paige-ayers -
Category
Documents
-
view
216 -
download
1
Transcript of Advanced Pump Management Gary Scheiner MS, CDE Integrated Diabetes Services 333 E. Lancaster Ave.,...
Advanced Pump Advanced Pump ManagementManagement
Gary Scheiner MS, CDEGary Scheiner MS, CDE
Integrated Diabetes ServicesIntegrated Diabetes Services333 E. Lancaster Ave., Suite 204333 E. Lancaster Ave., Suite 204
Wynnewood, PA 19096Wynnewood, PA 19096(877) 735-3648(877) 735-3648(610) 642-6055(610) 642-6055
www.integrateddiabetes.comwww.integrateddiabetes.comgary@[email protected]
The Pump Club of Greater Philadelphia
Advanced Pump Advanced Pump ManagementManagement
• Basal Insulin RegulationBasal Insulin Regulation
• Bolus RegulationBolus Regulation
• Physical Activity AdjustmentPhysical Activity Adjustment
• DKA PreventionDKA Prevention
• Temporary Basal RatesTemporary Basal Rates
• Prolonged BolusesProlonged Boluses
• Alternate Basal PatternsAlternate Basal Patterns
The Pump Club of Greater Philadelphia
Basal Insulin Basal Insulin RegulationRegulation
The Pump Club of Greater Philadelphia
• Basal Insulin’s One And Only Job Is To Basal Insulin’s One And Only Job Is To
Hold Blood Glucose Levels Hold Blood Glucose Levels SteadySteady In the In the
Absence of Confounding InfluencesAbsence of Confounding Influences**
* Food, Exercise, Bolus Insulin, Unusual Hormonal * Food, Exercise, Bolus Insulin, Unusual Hormonal Conditions (illness, rebounds, menstruation)Conditions (illness, rebounds, menstruation)
Basal Insulin Basal Insulin RegulationRegulation
The Pump Club of Greater Philadelphia
Conditions for Testing Basal Rates:Conditions for Testing Basal Rates:• No food or bolus for at least 4 hrs priorNo food or bolus for at least 4 hrs prior
• Last meal/snack low in fatLast meal/snack low in fat
• No food or bolus during test phase (water/diet drinks OK)No food or bolus during test phase (water/diet drinks OK)
• BG above 80, below 250 throughoutBG above 80, below 250 throughout
• No lows for previous 12 hrsNo lows for previous 12 hrs
• Stay connected, no stopping/suspendingStay connected, no stopping/suspending
• Exercise OK up until test phase (if usually performed)Exercise OK up until test phase (if usually performed)
• No heavy activity during test phaseNo heavy activity during test phase
• Do not run test if sick or just prior to/start of periodDo not run test if sick or just prior to/start of period
Basal Insulin Basal Insulin RegulationRegulation
The Pump Club of Greater Philadelphia
TestTest Last Meal / Last Meal / Bolus ByBolus By
Check BG atCheck BG at May Eat / May Eat / Bolus Again atBolus Again at
OvernightOvernight 6pm (skip 6pm (skip night snack)night snack)
10pm, 1am, 4am, 10pm, 1am, 4am, 7am7am
7am7am
MorningMorning 3am (skip 3am (skip breakfast)breakfast)
7am, 9am, 11am, 7am, 9am, 11am, 12noon12noon
12 noon12 noon
AfternoonAfternoon 8am (skip 8am (skip lunch)lunch)
12 noon, 2pm, 4pm, 12 noon, 2pm, 4pm, 5pm5pm
5pm5pm
EveningEvening 1pm (have 1pm (have late dinner)late dinner)
5pm, 7pm, 9pm, 5pm, 7pm, 9pm, 10pm10pm
10pm10pm
Sample Basal Testing Schedule
Basal Insulin Basal Insulin RegulationRegulation
The Pump Club of Greater Philadelphia
Average basal profiles*
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
12
-1a
1-2
a2
-3a
3-4
a4
-5a
5-6
a6
-7a
7-8
a8
-9a
9-1
0a
10
-11
a1
1-1
2p
12
-1p
1-2
p2
-3p
3-4
p4
-5p
5-6
p6
-7p
7-8
p8
-9p
9-1
0p
10
-11
p1
1-1
2a
units
/hou
r
age 11-20
age 21-60
age 3-10
age >60
* Diabetes Research & Clinical Practice (2005) 14-21.
Basal Insulin Basal Insulin RegulationRegulation
The Pump Club of Greater Philadelphia
Example 1: Sara Smiley
• Currently:Currently: .30 3am-9am, .30 3am-9am, .25 9am-3am.25 9am-3am
• Skipped BreakfastSkipped Breakfast
• BG results:BG results:
6am 1096am 109
8am 2018am 201
10am 23010am 230
12pm 22412pm 224
Interpretation:Sharp rise 6am-8am
Modest Rise 8am-10am
Stable 10am-12 noon
Adjustments: Basal by .1 5a-7a Basal by .05 7a-9a
Repeat test from 6a-12p
Bolus Insulin Bolus Insulin RegulationRegulation
The Pump Club of Greater Philadelphia
I:C Ratios:I:C Ratios:
• The correct ratio should match pre-meal BG 3-4 The correct ratio should match pre-meal BG 3-4 hours (not 2!) after eatinghours (not 2!) after eating
• I:C Ratio often varies from meal to mealI:C Ratio often varies from meal to meal
(bkfst dose > lunch & dinner)(bkfst dose > lunch & dinner)
Bolus Insulin Bolus Insulin RegulationRegulation
The Pump Club of Greater Philadelphia
Correction Boluses:Correction Boluses:• 1500-Rule (aggressive)1500-Rule (aggressive)
(Total Daily Ins.)/1500(Total Daily Ins.)/1500
• 1800-Rule (conservative)1800-Rule (conservative)
(Total Daily Ins.)/1800(Total Daily Ins.)/1800
• May vary day vs. nightMay vary day vs. night
(nighttime often 50% more than day)(nighttime often 50% more than day)
Physical Activity Physical Activity AdjustmentsAdjustments
The Pump Club of Greater Philadelphia
Activity Within 2 Hrs Activity Within 2 Hrs After MealAfter Meal
Activity Before or Activity Before or Between MealsBetween Meals
Short DurationShort Duration(<90 Minutes)(<90 Minutes)
Mealtime BolusMealtime Bolus Snack Prior to Activity*Snack Prior to Activity*
Long Duration (>90 Long Duration (>90 Minutes)Minutes)
Mealtime BolusMealtime Bolus Basal RateBasal RateSnack hourlySnack hourly
Basal RateBasal RateSnack hourlySnack hourly
Physical Activity Physical Activity AdjustmentsAdjustments
The Pump Club of Greater Philadelphia
Meal BolusMeal Bolus Adjustment*Adjustment*
Low Intensity Cardio Low Intensity Cardio 25% 25%
Mod. Intensity Cardio Mod. Intensity Cardio 33% 33%
High Intensity Cardio High Intensity Cardio 50% 50%
Competitive/Anaerobic Competitive/Anaerobic ??????
* If activity is after meal* If activity is after meal
Basal Basal Adjustment**Adjustment**
Basal rate 50%Basal rate 50%
Start basal reduction 1 hr Start basal reduction 1 hr pre-activitypre-activity
** For activities lasting > ** For activities lasting > 90 Min.90 Min.
Physical Activity Physical Activity AdjustmentsAdjustments
The Pump Club of Greater Philadelphia
• Snacking to prevent low (examples)Snacking to prevent low (examples)
Carbohydrate Replacement Per 60 Minutes of Activity
50 lbs 100 lbs 150 lbs 200 lbs 250 lbs
Skating 7-10g 14-20g 20-30g 28-40g 35-50g
Gymnastics 8-12g 17-23g 25-35g 34-46g 42-57g
Soccer 13-17g 27-33g 40-50g 54-66g 67-82g
Physical Activity Physical Activity AdjustmentsAdjustments
The Pump Club of Greater Philadelphia
Watch Out for D’OH!Watch Out for D’OH!(Delayed Onset Hypoglycemia)(Delayed Onset Hypoglycemia)
Following high-intensity Following high-intensity exerciseexercise
Following extended- Following extended- duration activityduration activity
May occur up to 24 hours May occur up to 24 hours afterwardsafterwards
Extra snacks or reduction Extra snacks or reduction in basal insulin may be in basal insulin may be necessarynecessary
Physical Activity Physical Activity AdjustmentsAdjustments
The Pump Club of Greater Philadelphia
OK To Disconnect Up To OK To Disconnect Up To 11 Hour w/ Activity Hour w/ Activity
Disconnection for 2 hours of exercise:Additive basal pulse action
Physical Activity Physical Activity AdjustmentsAdjustments
The Pump Club of Greater Philadelphia
Alternatives to Disconnection:Alternatives to Disconnection:
Wear It! (Sport Pack, Fanny Pack, Backpack Harness)
Re-Connect hourly & bolus 50% of missed basal rate
DKA DKA PreventionPrevention
The Pump Club of Greater Philadelphia
Normal Cellular MetabolismNormal Cellular Metabolism
(Body Cell)
Insulin
G
G
Fatty Acid
K Energy+
DKA DKA PreventionPrevention
The Pump Club of Greater Philadelphia
Metabolism Metabolism With With Insulin Insulin DeficiencyDeficiency
K
(Body Cell)
Insulin
G
Fatty Acid
Energy
K
K K KBlood StreamKidney
To Urine
K
K+
+
+ + +
+
DKA DKA PreventionPrevention
The Pump Club of Greater Philadelphia
Progression Progression to DKAto DKA
(Body Cell)
Blood Stream Kidney
To Urine
Fatty Acid
Fatty Acid
Fatty Acid
K
K
K
K
K
K
KK K
K
Liver
G
G
G
GG G GG
G
K
+ +
+ + +
+
+
++
++
ENERGY
Higher B.G.
+ More Ketones
+ Dehydration
**KETOACIDOSIS**
DKA DKA PreventionPrevention
The Pump Club of Greater Philadelphia
Causes of insulin deficiency in Pump TherapyCauses of insulin deficiency in Pump Therapy
Malabsorption (site problems)Malabsorption (site problems)
Insulin SpoilageInsulin Spoilage
Tubing or infusion set clogsTubing or infusion set clogs
Leaks where the cartridge connects to the tubingLeaks where the cartridge connects to the tubing
Air pockets in the tubingAir pockets in the tubing
Dislodgement of the canula from beneath the skinDislodgement of the canula from beneath the skin
Improper or insufficient primingImproper or insufficient priming
Extended pump suspension or disconnectionExtended pump suspension or disconnection
DKA DKA PreventionPrevention
The Pump Club of Greater Philadelphia
Unexplained High Blood Sugar
Check for Ketones
Ketones Ketones Negative Positive
Bolus w/Pump BS Doesn’t Drop 1. Shot w/Syringe
BS Drops 2. Drink Water 3. Change Out Pump
OK
Temporary Temporary Basal RatesBasal Rates
The Pump Club of Greater Philadelphia
• Basal Insulin Should Hold BG Basal Insulin Should Hold BG Steady Under Normal Conditions.Steady Under Normal Conditions.
• How Often Is Life Under “Normal How Often Is Life Under “Normal Conditions”?Conditions”?
Temporary Temporary Basal RatesBasal Rates
The Pump Club of Greater Philadelphia
• High-Fat FoodHigh-Fat Food
DurationDuration AdjustmentAdjustment NotesNotes
8:008:00 +60%+60% Start After Start After MealMeal
Temporary Temporary Basal RatesBasal Rates
The Pump Club of Greater Philadelphia
• IllnessIllness
DurationDuration AdjustmentAdjustment NotesNotes
24:0024:00 +80%+80% Repeat as Repeat as NeededNeeded
Temporary Temporary Basal RatesBasal Rates
The Pump Club of Greater Philadelphia
• Predictable Predictable StressStress
DurationDuration AdjustmentAdjustment NotesNotes
3:003:00 +80%+80% Set 1-2 Set 1-2 Hours PriorHours Prior
Temporary Temporary Basal RatesBasal Rates
The Pump Club of Greater Philadelphia
• Extended Extended InactivityInactivity
DurationDuration AdjustmentAdjustment NotesNotes
Varies Varies (>3 hrs)(>3 hrs)
+40%+40% Great for Great for long trips!long trips!
Temporary Temporary Basal RatesBasal Rates
The Pump Club of Greater Philadelphia
• Menstrual Menstrual CyclesCycles
DurationDuration AdjustmentAdjustment NotesNotes
12:0012:00 +50% (pre)+50% (pre) Start at nightStart at night
12:0012:00 -30% (post)-30% (post) Start at nightStart at night
Temporary Temporary Basal RatesBasal Rates
The Pump Club of Greater Philadelphia
• Prolonged Prolonged ActivityActivity
DurationDuration AdjustmentAdjustment NotesNotes
Minimum Minimum 2 hrs.2 hrs.
-50%-50% Start 1-2 Start 1-2 hours priorhours prior
Temporary Temporary Basal RatesBasal Rates
The Pump Club of Greater Philadelphia
• AlcoholAlcohol
DurationDuration AdjustmentAdjustment NotesNotes
2 hrs per 2 hrs per drinkdrink
-40%-40% Begin after Begin after drinkingdrinking
Prolonged Prolonged BolusesBoluses
The Pump Club of Greater Philadelphia
• DescriptionDescription
Normal/Standard Boluses are delivered within a Normal/Standard Boluses are delivered within a few minutes; peak is approx. 1 hr, duration few minutes; peak is approx. 1 hr, duration approx. 4 hoursapprox. 4 hours
Prolonged boluses are delivered over a period Prolonged boluses are delivered over a period of a couple of hours; peak is delayed/blunted of a couple of hours; peak is delayed/blunted and duration is extended.and duration is extended.
Prolonged Prolonged BolusesBoluses
The Pump Club of Greater Philadelphia
• PurposePurpose
To do a better job of matching the To do a better job of matching the blood sugar rise caused by slow-blood sugar rise caused by slow-digesting foods.digesting foods.
0 1 2 3 4 5
Rapid-DigestingMeal/SnackSlow-DigestingMeal/Snack
Prolonged Prolonged BolusesBoluses
The Pump Club of Greater Philadelphia
• ApplicationsApplications
Very Large PortionsVery Large Portions
Low-Glycemic-Index FoodsLow-Glycemic-Index Foods
Meals/Snacks that take a long time Meals/Snacks that take a long time to consumeto consume
Prolonged Prolonged BolusesBoluses
The Pump Club of Greater Philadelphia
Options for slow-digesting food:Options for slow-digesting food:
Normal BolusNormal Bolus
0 1 2 3 4 5
BG Rise
Insulin
Prolonged Prolonged BolusesBoluses
The Pump Club of Greater Philadelphia
Options for slow-digesting food:Options for slow-digesting food:
Square/Extended BolusSquare/Extended Bolus
0 1 2 3 4 5
BG Rise
Insulin
Prolonged Prolonged BolusesBoluses
The Pump Club of Greater Philadelphia
Options for slow-digesting food:Options for slow-digesting food:
Dual/Combination BolusDual/Combination Bolus
0 1 2 3 4 5
BG Rise
Insulin
AlternateAlternateBasal PatternsBasal Patterns
The Pump Club of Greater Philadelphia
• Called Called Pattern A/BPattern A/B (Medtronic), (Medtronic), Prog 2-4Prog 2-4 (Animas), (Animas), Pattern 1-4Pattern 1-4 (Deltec)(Deltec)
• Useful when basal changes are Useful when basal changes are needed for several days (or more) needed for several days (or more) in successionin succession
AlternateAlternateBasal PatternsBasal Patterns
The Pump Club of Greater Philadelphia
Menstrual cycle phasesMenstrual cycle phases
Extended illnessExtended illness
Recovery from surgeryRecovery from surgery
Periodic use of steroid medicationsPeriodic use of steroid medications
Seasonal sportsSeasonal sports
Off-day vs. work/school-dayOff-day vs. work/school-day
Extended travelExtended travel
Climate changesClimate changes
Potential Uses:Potential Uses:
The Ultimate The Ultimate Pump ChallengePump Challenge
The Pump Club of Greater Philadelphia