n.insulin-pumps.pdf - services.nhslothian.scot · INSULIN PUMPS PAGE 1 Introduction to Insulin Pump...
Transcript of n.insulin-pumps.pdf - services.nhslothian.scot · INSULIN PUMPS PAGE 1 Introduction to Insulin Pump...
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INSULIN PUMPS PAGE 1
Introduction to Insulin Pump Therapy
What is an insulin pump and how does it work?
• Aninsulinpumpisasmallelectronicdevicewhichprovidesacontinuousinfusionofveryfastactinginsulin(NovorapidorHumalog)intothesubcutaneoustissue(undertheskin).Itisdesignedtodeliverinsulininawaymoresimilartothepancreasofapersonwithoutdiabetes,thaninsulininjections.
• Thepumpisprogrammableandthesettingscanbechangedifrequiredbyactivatingtheon-screenmenus(patients/parentsaretrainedhowtochangethesettings).
• Insulinisdeliveredthroughaninfusionsetfromthepump,andashortplasticcannulawhichischangedevery2-3daysusinganeedleinsertionset(seethepicturebelow).
• AllpatientsrequireacontinuousinfusionofNovorapidorHumalogwhichactasbasal(orbackground)insulinandtheremaybeseveraldifferentbasalratesettingsoverthecourseoftheday.
• Insulinbolusesarerequired,inadditiontothebasalinsulin,whencarbohydrate-containingfoods/drinksareconsumed.Thebolusisgiventhroughthepump,andthesettingsfortheamountofinsulinrequiredforcarbohydratearepre-programmedintothepump.
• Aninsulinbolusisalsorequiredwhenthebloodglucosereadingishighandtheamountofinsulinrequired(correctionfactor)isprogrammedintothepump.
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Who is eligible for insulin pump therapy?
a) Foradults and children 12 years and olderthereasonsforrequiringapumpare:
• IfattemptstoreachtargethaemoglobinA1c(HbA1c)levelswithmultipledailyinjectionsresultinthepersonhaving‘disablinghypoglycaemia’.
• IfHbA1clevelshaveremainedhigh,above70mmol/mol,withmultipledailyinjectionsdespitethepersonand/ortheircarercarefullytryingtomanagetheirdiabetes.
b) Forchildren aged less than 12 years,pumptherapyisrecommendedasapossibletreatmentforallchildren.TheNICEguidelinesadvisethatchildrenwhouseinsulinpumptherapyshouldhaveatrialofmultipledailyinjectionswhentheyarebetweentheageof12and18years.
What does starting on insulin pump therapy involve?
Startinganinsulinpumprequiresabigcommitmentandtakesmoretimeandeffortthanmanagingdiabeteswithinjections.Ifyouputinthetimeandeffortitcanallowflexibilityandgoodbloodglucosecontrol.Itisnotaneasyoption!
The commitment includes:
• Frequentbloodglucosetesting(minimumof8testsperday).
• Keepingadailywrittendiaryofbloodglucoseresultsandevents.
• Veryaccuratecarbohydratecounting.
• Regularcommunicationwiththediabetesteamandclinicattendance.
IftheHbA1cbeforestartingpumptherapyisabove60mmol/mol,adropby7mmol/molshouldbeexpected.Thisneedstobemaintained.
What happens if I become/my child becomes unwell when on insulin pump therapy?
Itisvitaltounderstandtheincreasedriskofdevelopingdiabeticketoacidosiswhenusinginsulinpumptherapy,andbeabletomanagesickdaysappropriately.Theusual24houradvicelinewillnotbeabletoofferadviceforadjustmentofpumpsettings.Itmaybenecessaryinthesecircumstancestoreturntoinsulininjections.Thismaybethecaseifadmissiontohospitalisrequiredduetoillnesswithhighbloodglucosereadingsandhighbloodketones.
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The insulin given through the pump is very fast acting insulin, therefore progression to ketoacidosis can occur within four hours if you/your child are not receiving insulin from the pump.
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What other equipment is required?
Acomputerisrequiredtodownloadpumpdata,toreviewbloodglucosereadingsandpumpsettings.Thesedownloadsareemailedtothediabetesteambeforeclinics.
What happens if the insulin pump is damaged?
Youshouldinsurethepumponyourhomeinsurancepolicy.Inaddition,thereisacompanywarranty.
How long would it take to start insulin pump therapy?
Theclinicalneedandassessmentofsuitabilitywillbethedecidingfactorsforprogressingthroughtheprepumpprocess.Ifitisagreedthatapatientneedspumptherapythenanassessmentofpriorityisrequired.Anurgentrequirement,e.g.diabetesinababy,willtakepriority.
Thereisawaitinglistforinsulinpumptherapy.Peoplearestartedonpumpsingroupsoftwoorthree,dependingontheirage.Thediabetesteamcangiveyouguidanceastohowlongyouwouldbeexpectedtowaitforaninsulinpump.
What happens if insulin pump therapy is not working well?
ThepumpremainsthepropertyofNHSLothian.Youwillbeaskedtosignanagreementtoreturnthepumpifitisnotbeingusedappropriately.
Somepeopleexperiencedifficultieswithinsulinpumptherapy.Thediabetesteamwillsupportyouwithanydifficulties,howeverifyou/yourchilddecidethatyouwouldprefernottobeoninsulinpumptherapy,youcanconvertbacktoinsulininjections.ThepumpwouldthenbetakenbackbyNHSLothian.
What do I do if I/my child would like to try insulin pump therapy?
Ifyouareinterestedininsulinpumptherapypleasediscusswiththediabetesteamatyournextclinicvisit.
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PAGE 4INSULIN PUMPSINSULIN PUMPS
Pre Insulin Pump Process
Ifyouareinterestedininsulinpumptherapy,thisistheexpectedprocessfollowingyourinitialenquiry.
Family enquiry about insulin pump therapyDiscussionatclinic,andwritteninformationsenttofamily.
Cliniclettersent,includingdocumentationthatpumpinformationhasbeensent.
Family wish to proceedInitiationofpumpprocessatnextclinicvisit:
Familyneedtoanswerthreequestionsaboutinsulinpumptherapycorrectly.Pumpreferralsheetfilledinbydoctoratclinic.
Patients referred for pump therapy discussed at diabetes team meeting, last Monday of month
Patientaddedtopumpwaitinglist.Lettersenttofamilyconfirmingpatientonpumpwaitinglist.
Family invited to pump show
Referred for pre-pump psychology assessment
4 months before expected pump startPumpstartgroupsagreedbydiabetesteam.
Lettersenttofamilywithexpectedpumpstartdate.
4 months before expected pump startFamilymeetwithdietitian.
Dietitianassessmentandsignoff-acuratecarbohydratecounting.
3 months before expected pump start dateFamilymeetwithDNS.
DNSassessmentandsignoff-readinessforpumptherapyandexpectations.
2 months before expected pump start dateDatesandpaperworkforpumpstartsenttofamily
(seepumptrainingprogrammeprocess).
1 month before expected pump start datePumpdeliveredtofamilyhome.
Pumpagreementandpre-pumppreparationsheetsenttofamily.
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Insulin Pump Start Process
Week 1
Childrenundersevenyearsofage
Groupsoftwofamilies
Visit1–ParentsattendRHSCforinsulinpumpeducation
Visit2–ParentsandchildrenattendRHSCforinsulinpump‘saline’start
Childrenoversevenyearsofage
Groupsofthreefamilies
Visit1–ParentsandchildrenattendRHSCforinsulinpumpeducationandinsulinpump‘saline’start
Week 2
Groupsoffamiliesattendforreviewofprogressfollowinginsulinpumpsalinestart,and‘golive’insulinpumpinsulinstart
Telephoneoncalladviceanddailyfollowupphonecallsfromdiabetesteam
Week 3
FamilyphoneDNSonWednesdaytoreviewBGreadingsandprogress
Week 4
Beginningofweek-Familysendininsulinpumpdownloadsforprevioustwoweeks
Downloadstosend: Devicesettings
Quickviewsummary
Logbookdiary
Modaldaybyhour
Endofweek–FamiliesattendRHSCforgroupreviewandeducationsessionwithdiabetesteam
Week 8-10
ReviewappointmentinWednesdayafternoondiabetesreviewclinic
PumpdownloadsforprevioustwoweekstobesenttodiabetesteamonMondaybeforeclinic
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Top Tips When Starting on an Insulin Pump
Usethissectionasaguidefollowingyour/yourchild’spumpstartdate.Whenmoreexperiencedwithinsulinpumptherapy,youwillfindmoredetailedinformationinthe‘Day-to-DayInsulinPumpManagement’section.
1. When should BG readings be checked?
AimtocheckaBGreadingbeforeand2hoursaftercarbohydrateintake.Initially,alsocheckBGapproximately3hourlyovernighte.g.midnight,3amand6am.
RemembertorepeataBGreading1hourafteranysignificantpumpevente.g.setchange,treatingahypo,pencorrectionforhighbloodglucose/ketones.
BGreadingsshouldberecordedonthedailyrecordsheets,alongwithCHOintakeandinsulindosesforthefirstweekafterthepumpstart.Followingthis,youcanchangetotheMedtronicdailydiary,howeveryoumayprefertocontinueusingthedailyrecordsheetsforlonger.
2. What should I/my child eat and drink following the pump start?
Aimtoeatthreemealsperday.Asmallsnack,coveredwithabolus,betweenmealsisoptional.Ideallythereshouldbeatleast2hoursbetweenmealsandsnacksinitially,toassesstheinsulintocarbohydrateratios.
3. How does the pump calculate a bolus insulin dose?
Thepumpisprogrammedwithyourinsulintocarbohydrateratios,correctionfactor,andbloodglucosetargets.Thepumpcanthereforeworkouthowmuchbolusinsulinisrequired.Thereisalsoasafetyfeaturewhichpreventsanoverbolusofinsulin.Allthesefeaturesarecombinedinthepumpsoftware.Thebolusfunctioniscalledthe‘boluswizard’.
4. When should an insulin bolus be given?
Boluswizardshouldbeusedtocalculateanappropriateinsulinbolusforallcarbohydrateintake.Aimtogiveaninsulinbolus10minutesbeforemeals(upto20minutesbeforebreakfast),forthecarbohydratewhichyouknowyou/yourchildwilleat.IfmoreCHOthanexpectedisconsumed,bolusfortheadditionalCHOasitistaken.
Useboluswizardtoensurecorrectionbolusesaregivenwhenappropriate,everytimetheBGis>7mmol/L,throughoutthedayandnight.Ifthereisactiveinsulin,boluswizardwilltakethisintoaccount,andcalculatetheamountofcorrectionrequired.
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5. How do I manage hypoglycaemia on a pump?
Giveshortactingglucoseasyouwouldhavedonepreviously.BGshouldbere-checkedafter10-15minutes.
IftherepeatBGis<4mmol/L,repeatthehypomanagement.
Thereisnoneedtogiveextra‘free’carbohydratewhentheBGhasrisento>4mmol/Lwhileusinganinsulinpump,asalltheinsulininthepumpisveryfastactinginsulin.
AnyadditionalCHOconsumedshouldbecoveredwithinsulinasindicatedbytheboluswizard.
Iftherearetwoseparateepisodesofhypoglycaemiawithinonehour,setatemporarybasalrateof50%(see‘Managementofhypoglycaemiaonaninsulinpump’flowchartonpage15).
RepeattheBGonehourafterthehypohasbeensuccessfullytreated,orsoonerifyouareconcerned.
IftheBGis>7mmol/Lwithintwohoursoftreatingahypo,youshouldnotgiveacorrectionbolus.IfeatingadditionalCHO,enteraBGof7mmol/Ltothepump,itwillthenonlybolusforthecarbohydrate.
IftheBGis>7mmol/Lmorethantwohoursaftertreatingahypo,useboluswizardtocalculateacorrectionbolus.
6. How do I manage high blood glucose readings >14mmol/L on a pump?
Theinsulingiventhroughtheinsulinpumpisveryfastactinginsulin,thereforeketonescandeveloprapidlyifthereisanyinterruptiontoinsulindelivery.
ImmediateactionisrequirediftheBGis>14mmol/L,initiallybycheckingforketones.Seethe‘ManagementofHyperglycaemia’and‘InsulinPumpTherapyDuringIntercurrentIllness’flowcharts.
Hyperglycaemiacanoccurformanyreasons.Itisimportanttocheck:
• Thereisnoleakagefromtheinfusionsetorcannula.
• Thecannulahasnotbecomedislodged.
• Thecannulaandinsertionsethasnotbeenwornformorethan72hours.
• Therearenolargeairbubblesintheinfusionset.
• Thecorrectbasalrateisset.
• Thecorrectbolusdosehasbeengiven(checkbolushistory).
• Thecannulaisnotinsertedintoalumpysite.
• Thepumpisworkingproperly(doa‘selftest’).
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7. Can the insulin pump be disconnected?
Theinsulinpumpcanbedisconnectedforshortperiods,e.g.showering,dressing,datadownload.Aimtokeepthistimeasshortaspossible,notlongerthanonehour.
Smallchildrenareoftenonultralowbasalrates,whichwillbedeliveredatsettimes.
e.g. 0.025units/hour-thiswillbedeliveredasabolusoneachhour(00:00,01:00,02:00etc).
0.05units/hour-thiswillbedeliveredasabolusof0.025unitsoneachhalfhour(00:00,00:30,01:00,01:30etc).
Thereforedonotdisconnectthepumpatthesetimes.
8. What if I think there is a problem with the pump?
TreatahighBGfollowingthe‘Hyperglycaemia’flowchart(page16).
Doaselftest.Iftheproblempersists,contacttheMedtronichelpline.
Ifthepumphasfailed,youwillneedtoreverttoinsulininjections,usingyourprepumpstartinsulindoses.
9. How do I manage activity following the pump start?
Theexpectationisthatthepumpstartweekwillinitiallybea‘quiet’week.Wewillencourageagradualincreaseinactivitytonormallevelsafterthefirstfewdays.
Whenthereisplannedexercise,setatemporarybasalrate(70%oftheusualbasal)starting60minutesbeforeandcontinuinguntil60minutesaftertheplannedexercise.Atemporarybasalratecanbecancelledatanytime.
Ifthereisunplannedexercise,additionalcarbohydrateisrequired,justasyouhavedonepreviously,topreventahypo.Atemporarybasalratemaystillberequiredifexerciseismoderateandlastslongerthan30minutes.Theeffectofalowerbasalratetakesuptoanhourtohaveanybenefit,whichiswhytheextraCHOisneededatstartofexercise.
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Day-to-Day Insulin Pump Management
1. What are the blood glucose (BG) targets while on pump therapy?
Thebloodglucosetargetshouldbesetat5-7mmol/Lonthepump,toallowboluswizardtocorrecttothistarget.
Generally,BGreadingsbeforemealsandbeforebedof4-8mmol/Lareacceptable,andwouldnotpromptachangeinbasalinsulinrates.
Twohoursafterameal,aBGof<9mmol/Lisacceptable.
IftheBG2hoursafteramealisabovetarget,increasetheinsulintocarbohydrateratio(ICR)byapproximately10-20%.Youwillthereforemakingminoradjustmentsregularly.
Forexample,ifyouwereusing1unit:13grams,changeto1unit:11grams.
2. When should insulin boluses to cover carbohydrate be given?
Givethebolustocovercarbohydrate10minutesbeforethemeal(orupto20minutesbeforebreakfast),forwhatyouknowwillbeeaten.Thiswillresultinoptimalbloodglucosecontrol.
BolusforanyadditionalCHOassoonasitiseaten(withoutenteringarepeatBG).
Rememberthatinsulinisabsorbedmorequicklybytheeffectsofexerciseandheat.Donotwait10-20minutesbeforeeatingifimmediatelyafterahypo.
3. How do I know if the basal rates need to be adjusted?
Wesuggestthatyouperformabasalratereviewevery4-6weeks.Reviewonlyonetimeintervalperday.
Ifbloodglucoseis4-8mmol/Lbeforeamealoratbedtime,omitthenextmealandsnack(orgiveaCHOfreemeal/snack)andcheckBGeverytwohours.Foranovernightbasalreview,havealightlowfatmealat5pm,thennothingafterwards.
TheBGshouldstaywithin2mmol/LoftheoriginalBGreading.
Carryoutthebasalratereviewprocessfrom:
a) Beforebreakfasttobeforelunch
b) Beforelunchtobeforetea
c) Beforeteatoafterbedtime
d) Overnight
Ifthebloodglucoselevelsriseorfallbymorethan2mmol/L,makeadjustmentstothebasalratestwohoursbeforetheriseorfall.
Whileperformingabasalratereview,donotgiveacorrectionbolusunlesstheBGis>14mmol/L,sothatyoucanseethebasalpatternclearly.
Once stable, checking BG before and 2 hours after meals as an 8 point profile is the ideal daily profile.
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Wesuggestthefollowingchanges,basedontotaldailydoseofinsulin(TDD):
TDD Adjustment
TDDlessthan10units makeadjustmentsby0.025unitsperhour
TDD10-20unitsperday makeadjustmentsby0.05unitsperhour
TDD20-40unitsperday makeadjustmentsby0.1unitsperhour
TDDgreaterthan40unitsperday makeadjustmentsby0.2unitsperhour
Example
TDDofinsulinonpump:15.6unitsperday
Overnightbasalreview
1800–Lightmeal,30gCHOeaten,bolusgivenviaboluswizard.
Time Basal rate (units/hour) Blood glucose (mmol/L)
18:00 0.25 5.4
20:00 0.45 7.3
22:00 0.45 12.1
24:00 0.3 12.2
02:00 0.3 11.8
04:00 0.3 9.4
06:00 0.3 9.2
RiseinBG>2mmol/Lat22:00,soincreasethebasalrate2hoursbeforethisrise.
TDD15.6unitsperday,sochangebasalrateby0.05unitsperhour.
Newbasalrateat20:00=0.45+0.05=0.5unitsperhour.
4. Which insertion sites should be used, and how often do they need to be changed?
Cannulascanbesitedintheabdomen,thighs,hipsortopsofbuttocks.Thereisusuallytoolittlefatonayoungchild'sabdomentousethisasaninsertionsite.
Thecannulaneedstobere-sitedeverytwoorthreedays.
IfyouseetheBGtrendrisingcominguptothethirdday,thenyouwillneedtore-sitethecannulaeverysecondday.Thisismorecommoninyoungerchildren.
Aimtore-sitethecannulabeforeamealsothatyoucanbesurethesetisworking.
Avoidre-sitingthecannulabeforebed,asitwilltakesomehourstoseearisingBGifthereisaproblemwiththenewinsertionsiteandthebasalinsulinisnotinfusing.
Document the basal rate review readings, the date and any changes made in the diary.
Remember to rotate insertion sites – lumpy sites remain a common problem.
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5. What is insulin sensitivity and what should it be set as?
Thisisthesameasa‘correctionfactor’.
Reviewthetotaldailydoseofinsulin(TDD)inutilities.Dividethisnumberinto100.Thisisyourinsulinsensitivity.
For example:
TDD=21units
Insulinsensitivity=100dividedby21=4.7
1unitofinsulinreducestheBGby4.7mmol/L
Thiscanbeadjustedfordifferenttimesoftheday,e.g.overnightmaybe1unitlowersby6mmol/L.
6. What is active insulin, and what should it be set as?
Activeinsulinisthebolusinsulinwhichhasbeendeliveredtoyourbody,buthasnotyetbeenused.Theactiveinsulinsettingmeansthedurationofinsulinaction,orhowlongabolusofinsulinwillremainactiveinthebodyforafteritisgiven.Thisisusuallysetas3hours.
Thiscanonlybecheckedifyouareconfidentthatthebasalratesarecorrect.
Youcanassesstheactiveinsulinprofilewithabolus:checkaBGbeforeameal,iftheBGisintarget,eatalowfatmealwithknownCHOcontent,usingboluswizardtogiveanormalbolus.
ChecktheBGhourlyforupto5hoursafterthemeal.Donoteatordrinkanysnacksorcarbohydratecontainingliquids,anddonotpartakeinanyexerciseoverthisperiod.
ReviewhowlongittakesfortheBGtocomebacktothepremeallevel(+/-2mmol/L).Ifitcomesbacktorangein3hours,activeinsulinshouldbesetas3hoursonthepump.Ifittakesalongerorshortertimetocomebacktorange,theactiveinsulincanbeadjustedaccordingly.
7. What are composite boluses?
Square wave: thebolusisgivenevenlyoveraperiodoftime(setfrom0.5–8hours).
Thisisusefulforhighfatmeals,lowglycaemicindex(GI)foods,orextendedmeals(e.g.buffets).AhighBGbeforethemealneedstobecorrectedwithaseparatenormalbolus.
Dual wave: thisisacombinationofanimmediatenormalbolus,followedbyasquarewavebolus.
ThisisusefulformealswithbothrapidlyandslowlyabsorbedCHO.Whensettingupadualwavebolus,yousetboththepercentageofinsulingivenbynormalandsquarewavebolus,andthetimethesquarewaveisgivenover.AhighpremealBGcanalsobecorrectedwithadualwavebolus.
e.g.50%normalbolus50%squarebolusover4hours.
Seetheexample:Medtronichandbook(page98/99)
Insulin sensitivity = 100 divided by TDD
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Exercise and Activity on Insulin Pump Therapy
Keep a record of what you do, as you will learn what best suits you/your child with time and experience.
When should I check a BG?
Check a BG before exercise
AimforaBG6-8mmol/Lbeforeexercise.
IftheBGis4-6mmol/L,giveasmall‘free’carbohydratesnackbeforeexercise(i.e.donotcoverthiswithabolus).
IftheBGisabove8mmol/Ltherearetwooptions:
1. Giveacorrectionbolus,andthengiveextrafreeCHOfree(seebelow).ThisisthebestoptioniftheBGis>10mmol/L.
2. Donotgiveacorrectionbolus,anddon’tgiveadditionalfreeCHOforbrief/moderateexercise.ThisisthebestoptioniftheBGis8-10mmol/L.
IftheBGis>15mmol/Lwithketones-don’texercise.Followthe‘Hyperglycaemia’flowchart(seepage16).
IftheBGis>15mmol/Lwithoutketones–itisstilloktoexercise,e.g.justafteramealwhenreducedinsulinwasgiveninpreparationforexercise.
Check BG at least hourly during sport
Thismayneedtobemorefrequentsoonafterstartingpumptherapytolearnyour/yourchild’sownresponse.
Check BG after sport
ConsiderreplenishingenergystoreswithadditionalCHO(seeexercisemanagementsection).
How do I manage mild to moderate activity?
Mild or brief activity
Ifexerciseisbriefandmild,donotalterthebasalrates,anddonotremovethepump.SomepeoplefindtheyneedasmallamountofadditionalCHO,e.g.0.25gofCHOperkgofbodyweightperhourofactivity.
Planned moderate activity
Ifexerciseifplanned,youshouldsetatemporarybasalrate.Thereducedbasalrateshouldstart60minutesbeforetheexercise,andcontinueforatleast60minutesaftertheexercise.Thismayneedtobetailoredaccordingtotheresponseinbloodglucose.Weadvisestartingwitha30%reduction(i.e.setas70%temporarybasal),butthiscanvaryfrom10-50%reduction.
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Example 1
Thesunhasjustcomeoutsoyouaregoingtotakeyourchildtotheplaypark,hopefullyforabout1hourifitstaysdry.Yourchildweighs20kg.TheirBGis6.3mmol/Lbeforeyouleavehome.
Whileattheparkyourchildwillbedoingmoderateexercise.
Moderateexercise,soneed0.5g/kg/hrofCHO,i.e.0.5x20x1=10gperhour(or5gfor30minutes)withoutabolus!
Thiscanbeadjustedwithexperienceanddependingonyourchild'sactivitylevelwhileatthepark.
Example 2
Yourchildhasfootballtrainingfrom3.30pmtill4.30pm.Yousetatemporarybasalratestartingat2.30pm(60minutesbeforefootballtrainingbegins),witha30%reduction(setas70%temporarybasal).Yousetthisfor3hours(i.e.60minutesbefore,60minutesduring,and60minutesafterfootball).
Youtestyourchild’sBGjustbeforeyouleaveanditis9.8mmol/L.Thisisabovetarget,butyoudonotgiveacorrectionbolus,asyouknowhehashadlessinsulinforthelast60minutes.YoucheckhisBGafter30minutesoffootballanditis6.8mmol/L,sohehasadrinkofwater.
Justattheendoffootballtraining,yourchild’sBGis4.6mmol/L.Youleavethetemporarybasalonforanother60minutes,andplantocheckaBGatthistime.
Unplanned moderate activity
Ifexerciseisunplanned,ortheduration/intensityisunknown,theonlyoptionistotakeadditionalCHOatthebeginningofandduringexercise.Youshouldalsoseta70%temporarybasalatthebeginningoftheactivity,fortheexpectedlengthofactivity,and60minutesafterwards.Thiscanbecancelledatanytime,forexampleiftheperiodofactivitydoesnotlastaslongasexpected.
Ifexerciseismoderate,consumeadditionalCHO.Approximately0.5gofCHOperkgofbodyweightisneededperhourformoderateactivity.DonotbolusforthisCHO,ifyouhavenotsetatemporarybasalrate60minutespriortoactivitystarting.
Altering bolus insulin with moderate exercise
Ifexerciseiswithin2hoursofameal,thebolusinsulincanbereduced.Thisishelpfulforplannedexerciseofknownintensityandduration.ItavoidstheneedforextraCHOonafullstomach.WorkouthowmuchCHOisneededfortheexercise.SubtractthisamountofCHOfromtheamountduetobeeatenatthemeal,thenbolusfortheremainingamountofCHO.
e.g. Youweigh30kg,andyouaregoingtoexercise(moderately)foronehour.
Moderateexercise,soyouneed0.5g/kg/hrofCHOi.e.0.5x30x1=15gofCHOperhour.
Youareabouttoeatamealcontaining75gofCHO.
Yousubtract15gofCHO(forexercise)from75gi.e.75g-15g=60g.
Youbolusfor60gofCHO.
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How do I manage strenuous activity?
Check a BG before exercise
TheBGbeforestrenuousexercisemustbe5-15mmol/L,ideally5-10mmol/L.ThehigherlimitwouldonlybeacceptableifyouhaveeatenCHOwithoutabolus,orwithareducedbolus,orusedareducedtemporarybasalrateinpreparationforexercise.
Set a temporary basal rate
Consideratemporarybasale.g.30-70%reduction(setas70%to30%temporarybasalrate),beginning60–90minutesbefore,andcontinuing60-90minutesafterstrenuousexercise.
Aperiodof4-8hoursoftemporarybasalrate(50-70%ofusualbasalrate)mayberequiredfollowingexhausting/prolongedactivity,duetotheriskofdelayedhypoglycaemia.
Consume additional carbohydrate
Thismayberequiredinadditiontosettingatemporarybasalrate.Youneedabout1gofCHOperkgofbodyweightperhourofexercise,andthiswouldnotbecoveredwithabolus.ExperiencewillbegainedbyrecordingBG’sduringandafterexercise.IftakinganyadditionalCHO,useareducedboluse.g.50%lessthanwouldusuallybegiven.
Reduce the bolus insulin after exercise
Thebolusinsulinforamealafterstrenuousexercisecanalsobereducedby30-70%,dependingontheactivity–seethe‘ExerciseandSportsection’fordetails.
Can I remove the pump during exercise?
Youcandisconnecttheinsulinpumpduringsportifrequired,forexample,forcontactsports,orduringstrenuousactivitythatyouknowhaspreviouslyresultedinhypoglycaemiadespiteatemporarybasalandadditionalcarbohydrate.
Pumpscanbedisconnectedforuptoonehour.YoumustcheckaBGduringexerciseifthepumpisdisconnected.
Withexperience,longersessionsoffthepumpcanbemanaged.Pleasediscussthiswiththediabetesteam,asfurtherindividualisedinformationisavailable.
Check BG regularly during and after strenuous exercise. Recording BG’s, pump settings and CHO intake will help to guide management of future exercise sessions.
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Notes (A)• Onaninsulinpump,onceBG>4mmol/Lasnackisnotessential.
• IfgivingfoodgiveaninsulinbolusforCHOusingcurrentinsulin:CHOratiousingboluswizard.
• Bolusmaybegivenafterfoodifpoortoleration/vomitinganticipated.
• DonotgiveacorrectionforBG>7mmol/Lfor2hoursafterhypotreatment.IfBG>7mmol/Ltheninput7mmol/Lintothepumptoensureacorrectionisnotgiven.
Notes (B)• Considerreasonbehindfrequenthypoglycaemia,i.e.intercurrentlyunwell,exercise-related,orthereisapatternofhyposdeveloping.
• Ifthereisapatternthenconsidertakingaction,i.e.seekmedicaladviceifunwell,considerlookingattheexercisemanagementroutineorconsidermakingalterationstobasalratesettings.
Give glucose as usual(10g of glucose, or see Hypoglycaemia section page 5)
Wait 10-15 minutes then recheck BG
BG now ≥4mmol/L(See Notes (A) below for further guidance)
Check BG 1-2 hourlyAim for BG target levels 5-7mmol/L
Hypoglycaemia twice in 1 hour OR 3 or more times in 2 hours
(See Notes (B))
Set a temporary basal rate at 50% for 2 hours
After 2 hours – Re-check BGAim for BG target levels 5-7mmol/L
BG remains <4mmol/L
Management of Hypoglycaemia BG <4mmol/L
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<1.0mmol/L
Give correction bolus via pump and re-check blood glucose in 1 hour
BG
Carry on as normal and give further
corrections if required
yes
no
* Correctionbolusviapen:Giveasperthe‘SickDayManagement’flowchart.Youneedtoknowthetotaldailydose(TDD)ofinsulin(inutilitiesmenuonpump).Youwillrequirea10%or20%(ofTDD)correctiondependingonyourbloodglucoseandbloodketones.
**Onceyouhavegiventhepeninjection,disconnectthepumpandsetthepumptodeliverthesamebolusdosegivenbypeninjection.Allowthistorunthroughthetubinganddiscardit(e.g.intothesink/ontothefloor),beforereconnectingthepump.Thismeansthatthecorrectiondosewillbeshownonthepumpdownloads,andincludedinthepump’sactiveinsulincalculation.
no
yes
yes
no
≥1.0mmol/L
1. Give correction bolus via PEN device*
2. Remove pump and run bolus through set**
3. Change pump infusion set
4. Check insulin pump (self-test)
Re-check blood glucose in 1 hour
BG
Re-check blood glucose and blood ketones
in further 1 hour
BG blood ketones
Management of Hyperglycaemia BG ≥14mmol/L
Check ketones
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Consider temporary basal rate
by further 25%
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Continue to check BG 2 hourly until levels remain within target and blood ketones are <0.5mmol/L on normal basal rates
Levels reach targetyes
Insulin Pump Therapy During Intercurrent Illness
Blood glucose (BG) level ≥14mmol/L and ketones present Follow Hyperglycaemia Guidelines (page 20)
Blood glucose levels remaining above target Unwell and requiring additional background insulin
Check BG and ketones 1-2 hourly Aim for BG target levels 5-7mmol/L
Set a temporary basal rate at 125% for 2 hours
After 2 hours – Re-check BG and ketone levels
Notes
• Ensureplentyofsugar-freefluidsifthebloodglucoseishigh.
• Ensureadequatecarbohydrateintake.
• Aninsulinbolusmustbegiventocovercarbohydratecontentoffoodandfluids.
• Ifmanagingtoeat,thebolusinsulindosemayneedtobeincreasedtemporarilye.g.ifusuallyusinginsulintoCHOratio1unit:10g,changeto1unit:8g.
no
Consider or stop temporary basal rate
Levels Levels steady
Continue temporary basal
Levels
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Troubleshooting – Pump Failure
What can cause a pump to stop delivering insulin?
• Thebatterycanrunout–thiswillnothappenwithoutwarningandyouhavebeensuppliedwithsparebatteries.
• Thepumpcanbedropped.
• Thepumpcanbedisconnectedbyaccident.
• Insulincanleakoutofagivingsetifitisnotconnectedproperly.
What do I do if I suspect a pump problem?
• Checkabloodglucosereading.
• IftheBGis>14mmol/L,checkforketonesandfollowthehyperglycaemia/intercurrentillnessflowchart.
• Changetheinfusionset.
• Ifatechnicalproblemwiththepumpissuspected,runa‘self-test’.(Dothisifthepumphasbeendropped).
• Ifthisdoesnotresolvetheproblem,removethepumpandswitchtosubcutaneousinsulininjectionsbybasalbolusregimen.
• Contactpumpcompanyfortechnicalhelp.
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Telephone Advice
General advice
Itisexpectedthattheinformationgivenwhenyoucommencetheinsulinpumpwillallowyoutomanageproblemsthatariserelatingtodiabetes.
Telephoneadvicecanbeobtainedduringnormalofficehoursbycontactingthediabetesnursespecialists(0131 536 0375).
Pleasenotethatadviceregardingthemanagementofinsulinpumpsisnotavailableout-of-hours(i.e.evenings,weekendsandholidays).
Shouldyouencounterdifficultiesthatyouarenotabletosolveusingtheinformationthathasbeenprovided,youshoulddisconnectthepumpandrevertbacktosubcutaneousinsulininjections.
How do I switch from the insulin pump to insulin injections?
Theamountofinsulinrequiredbyinjectiondependsonthetotaldailydose(TDD)ofinsulinonthepump.Thisinformationcanbeobtainedfromthedailytotalsmenuonthepump(utilitiesmenu.
How do I calculate the dose of insulin required by injection?
Option 1Findthecurrenttotaldailybasalinsulindosein‘utilities-dailytotals’menu.Givethisaseitherlantusoncedaily,ordividebytwo,andgiveaslevemirtwiceaday.
Forbolusinsulindoses,usethecurrentinsulin:CHOratiosandinsulinsensitivity(correctionfactor)fromthepump(Novorapid/Humalog).
Option 2Usethelasttotaldailydoseofinsulin(TDD),eitherfromthe‘utilities-dailytotals’menu,thelastdiabetesclinicletter,orarecentpumpdownload.SplittheTDDinto50%basaland50%bolus.Basalinsulincaneitherbegivenaslantusoncedaily,ordividebytwoandgiveaslevemirtwiceaday.
Forbolusinsulindoses,usethecurrentinsulin:CHOratiosandinsulinsensitivity(correctionfactor)fromthepump(Novorapid/Humalog).
Option 3Ifthepumphasfailedandyoucannotaccessthesettings,andyoudonothavearecentdiabetesclinicletter,orarecentpumpdownload,estimatethetotaldailydoseofinsulin(TDD)by:
TDD=Weight(kg)x0.8
Dividethisinto50%basaland50%bolus.Givethebasalinsulinaslantusoncedaily,ordividebytwoandgiveaslevemirtwiceaday.
Ifyoudonotknowthecurrentinsulin:CHOratios,the50%bolusinsulincanbedividedbythreeandgivenateachmeal(Novorapid/Humalog).
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Additional very fast acting insulin may be required outside of mealtimes as per the Sick Day Management section.
Example
TDDoninsulinpump 24units
50%basal 12unitsLevemir6unitsinthemorningand6unitsintheeveningORLantus12unitsoncedaily.
50%bolus Usetheinsulintocarbohydrateratioandcorrectionfactorfromthepumpsettingsatmealtimes.Alternatively12units(4unitsatbreakfast,4unitsatlunch,4unitsattea)
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Admission to Hospital While on an Insulin Pump
Insomesituationsitispossibletocontinueonaninsulinpumpifyou/yourchildare/isadmittedtohospital,howevertheremaybereasonswhyitisdeemedsafertodiscontinuetheinsulinpumpandswitchtosubcutaneousinjectionsduringahospitaladmission.
When is it not possible to continue on an insulin pump in hospital?
Inthefollowingsituationsyou/yourchildmustremovetheinsulinpumpandswitchimmediatelytoinsulinbysubcutaneousinjectionorIVinsulininfusion.
• Diabeticketoacidosis–thepumpwillbedisconnectedandinsulinandfluidswillbestartedthroughaninfusionintothevein.
• Ifyou/yourchildare/isdrowsyorunconscious.
• Ifyou/yourchildare/isseriouslyillandrequireadmissiontotheintensivecareunit.
• Ifthereisnoonecontinuouslypresentontheward(parentorcarer)toperformallpumpcare.
• Ifyou/yourchildhaveamajorpsychiatricdisturbance.
• Ifyoudonothaveenoughconsumables(parentsshouldhaveallconsumablesrequiredforthedurationoftheadmission).
• Othersituationsasdeterminedbythemedicalstaff.
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Guidance for In-patients Remaining on an Insulin Pump
Providingtherearenocontra-indications(aslistedabove)patientsmayremainontheirinsulinpump.Itisexpectedthattheparent/carerwillberesponsibleforthemanagementoftheinsulinpumpatalltimes duringtheadmission.
What documentation is needed for in-patients on insulin pumps?
• Wewillaskyoutosignaformindicatingthatyouwillberesponsibleformanagingyourchild’spumpanddocumentingpumpsettings.
• Wewillaskyoutodocumentthebasalrates,bloodglucose,bloodketones,carbohydrateintakeandbolusinsulingivenondailydiarysheets(thesameasthoseusedafterthepumpstart).
Who will operate the insulin pump on the ward?
• Aparentorguardianmustbeabletostaywiththechildatalltimesduringtheadmission.
• You/yourchildmustoperatethepumpduringtheadmission.
• You/yourchildmustmakeanyadjustmentsonthepump.
• Theflowchartsformanagementofhypoglycaemia/hyperglycaemiaandsickdayswillbeavailableontheward.
What happens if my child needs to have an operation?
Theinsulinpumpmayberemovedforshortprocedures(thetotaltimeoffthepumpshouldnotbemorethan60minutes)suchasforanMRIorCTscan.Iftheprocedurewilltakelongerthan60minutes,itmaybepossibletostayonthepumpwithguidancefromthediabetesteam,butitmaybenecessarytocomeoffthepumpandswitchtoinsulininjectionsoraninfusionofinsulinintoavein.
Radiology investigations
• TheinsulinpumpmustberemovedbeforeenteringtheMRI/CTsuite.ThisisbecausethemagnetintheMRIscannerwillcausethepumptofail.
Minor surgery
• Insulinpumpsmaybeused,continuingonabasalrateduringfastingperiodsandthesurgicalprocedure.
• Thediabetesteamwilldiscusswiththeanaesthetistpriortotheprocedure.Bloodglucosewillbemonitoredhalf-hourlyduringtheprocedure.
• Bolusescanbegiventhroughthepumpasusual,onceeatinganddrinkingaftertheprocedure.
Major surgery
• Thepumpneedstoberemovedandaninfusionofinsulinthroughadripintotheveinwillbecommenced.
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Parent/Carer Consent Form
Continuation of insulin pump therapy during in-patient stay
Foryourchild’ssafetyduringthisadmission,werequestthatyouagreetothefollowingrecommendations.Ifyoufeelthatyoucannotagreetotheserecommendations,wewouldliketotreatyourchild’sdiabeteswithinsulininjectionsandrequestthatyoudiscontinuetheuseofyourchild’sinsulinpump.
As the parent/carer during my child’s admission to hospital:
• Iamtrainedtousetheinsulinpumpandwillremaininthehospitalforthedurationoftheadmission.
• Iwillmanagetheinsulinpumpduringtheadmission.
• Iwillprovidealltheequipment,consumablesandinsulinrequiredforthedurationoftheadmission.
• Iwillrecordthepumpsettings,basalrates,bloodglucose,ketones,carbohydrateintake,insulinbolusesonthe‘insulinpumpin-patientrecord’chartwhichwillbekeptintheyellowfolderbythebedside.
• Iwillallownursingandmedicalstafftohaveaccesstothe‘insulinpumpin-patientrecord’atalltimes.
• Iwillchangetheinfusionsetevery48–72hoursorasrequiredaccordingtothehyperglycaemiaorintercurrentillnessflowchart.
• IfIcannotmanagethepump,theinsulininfusionpumpwillbedisconnectedandinsulininjectionscommenced.
I also understand that the pump may be discontinued and a different insulin delivery given for any of the following:
• Contra-indications(aslistedabove).
• Therequestoftheconsultantresponsibleforthepatientduringtheadmission.
• Anx-rayprocedure(mayincludepumpremovalbytubingdisconnectand/orremovalofthepumpandtubing).
Parent/Carer
Signature............................................ Print................................................. Date...................
Witness
Signature............................................ Print................................................. Date...................
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