Practical Aspects of Insulin Pumping

DeAnn Johnson, RN, BSN, CDESusie 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

*= p<0.001, †=p<0.05. The pre-CSII values for each year represent the initial values for only those with an HbA1c value in that year.

HbA1c Values(1 year pre-CSII compared to each year)

6.5

7

7.5

8

8.5

9

1 2 3 4 5 6 7 8

Years on CSII

HbA

1c v

alue

(%)

Pre-CSII

Most Recent

* * † † ††

† †

n=291 n=267 n=196 n=146 n=105n=59

n=34 n=11

Chase HP et al, Diabetes Technology& Therapeutics, 9:421,2007

Figure: The Decline of Severe Hypoglycemic Events with CSII Therapy in a General Clinic Population

02468

101214

Pre-CSII On CSII Pre-CSII On CSII

Rat

e of

hyp

ogly

cem

ia

(eve

nts

per 1

00 p

atie

nt-

year

s)

* **

Severe Hypoglycemia and Insulin Pumps (CSII)

* Maniatis, Chase, et al. Pediatri,107,351 2001

(In DCCT: 62per 100 pt. yrs: NEJM, 329, 977, 1993)

** Scrimgeour, Chase, et al D T & T 9:421, 2007

Who’s a good candidate?

Essential Criteria for Pump InitiationSurvey of 54 Diabetes Educators

Lenhard et. al., Infusystems USA 3, 1, 2006

* All 54 respondents ranked SMBG as an essential criteria for pump start

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.

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

From Holterhus PM, et al., Diabetes Care, 2007; 30(3):568-73.

B and C= 708 and 83 primarily pubertal subjectsD = 152 subjectsF = 117 pre-pubertal subjects

Basal Dosing Needs

Bolus Dosing Consider using “Rule of 500 (carbs)

& Rule of 1700 (correction)” Bolus 15-30 minutes prior to meal

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

-1

0

1

2

3

4

5

1 Bolus 2 boluses Square wave Dual Wave

Method of bolus administration

Chan

ge in

blo

od g

luco

se le

vels

(mm

ol/L

)

2-hour post-prandial4-hour post-prandial

Dual Wave Bolusing

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

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

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.

Exercise

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.

Choosing the Right Site and Set

Site and Set Considerations

Pinch test Hypertrophy/lipo-

atrophy Curves Disconnection access Diapers Activities

90 Degree Infusion Sets

Cleo

InsetSure T

Quick set

Rapid D

Angled Infusion sets

Inset 30

Omnipod

ComfortSilhouetteTender

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.

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)

Where to wear?

alana-mireilleapparel.com

Kangaroo Pump Pockets

Mypumpgear.com

Pumpwearinc.com

store.minimed.com

Wearing the Pump

Cell Phone/PDA Holders as Pump/PDM Holders

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

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

Vacations

10-50% reduction in dosages

Travel letter and current dosing

Take along “loaner pump” and/or basal insulin & syringes

More frequent set changes