Presented by Susie Heaton, MS, RD, CDE. Basal rates Insulin to Carbohydrate Ratio (I:C) Insulin...

Insulin Pump Management

Presented by Susie Heaton, MS, RD, CDE

Pump Settings to Evaluate

Basal rates Insulin to Carbohydrate Ratio (I:C) Insulin Sensitivity Factor (ISF) Pump Download and History Infusion site issues Combo Bolus Case Studies

Basal Rates

Basal rates that are set correctly should keep your BG relatively stable in the absence of food, exercise or extra insulin

Basal rates should be evaluated when there is variability in BG readings, change of season, significant weight changes or change in physical status

Basal Testing Tips

Divide day into 4 time frames and evaluate one time frame at a time.

Evaluations begin 4-5 hours after the last bolus dose and food consumption.

Starting bg should be around 90-150 mg/dl Testing is stopped if bg goes above 150 or

below 90. Repeat test 2-3 times before making

adjustments.

Basal Rate Test: Overnight

What to do When to test

• Eat dinner (low fat, known carbohydrate content meal)

• Bolus for dinner• Nothing to eat until

breakfast

• 4 hours after dinner• At bedtime• At midnight• At 2-3 am• Every 3 hours

when awake

• BG must be in target range four hours after dinner to start this test.

Basal Rate Test: Daytime

What to do When to testMorning • Skip breakfast• No food until lunch

• Test every 1-2 hours until lunch

Afternoon• Skip lunch• No food until dinner

• Start to test 4 hours after breakfast• Test every 1-2 hours until dinner

Evening• Skip dinner• No food until bedtime

• Start to test 4 hours after lunch • Test every 1-2 hours until bedtime

BG must be in target range four hours after meal to start test. Each daytime segment should be tested on a different day.

Looking at the Data

BG swings of more than 30 mg/dl indicates the need for basal adjustments

It is best to see repeating trends before making changes

Basal rate should be increased or decreased 1-2 hours before the BG begins to rise or fall.

Make one change at a time

Suggested Guidelines for Basal Adjustments

•Make adjustments in 0.200 unit increments

Basal of 2.0 units per hour

or more


Basal of 0.5-1.9 units per

hour


Basal of 0.3-0.5 units per

hour


Basal less than 0.3 units per

hour

What should we do?

Time 10 pm 12 am 3 am 6 am

BG test #1 149 130 86 61

BG test #2 131 119 77 59

BG test #3 122 110 73 55

Basal 0.550 0.550 0.550 0.550

Suggested Changes

Decrease basal at 12 am to 0.450

Calculating I:C Ratio

I:C indicates how many grams of carbohydrate 1 unit of rapid-acting insulin will cover

Determine starting point for I:C ratio500 ÷ TDD (Total Daily Dose) = I:CExample: 500 ÷ 50 U = 10 (I:C= 1:10)

May have more than one I:C for different meals or times of day

Insulin to Carbohydrate (I:C) Ratio

After basal settings have been confirmed, you can evaluate bolus dosages

If the BG consistently returns to target range about 4 hours after meals, you can be confident that the I:C ratio is working well

If the BG does not return to target range 4 hours after meals, you should evaluate the I:C ratio

Checking I:C Ratio

What to do When to test

• Start before meal • Assure BG in target range (90-

140 mg/dl)• Assure known amount of

carbohydrate and low fat meal• Bolus for meal

• Test BG hourly for 5 hours

Recommended Goals

1 hour after meal• BG 40-80 mg/dL higher than pre-

meal

4 hours after meal• BG within 30 mg/dL of pre-meal

Adjusting I:C Ratio

Result Adjustment

BG more than 30 mg/dL below pre-meal

Re-check ratio another time using a higher I:C (higher I:C will reduce size of bolus)

BG within 30 mg/dL of start

Carbohydrate ratio is correct

BG more than 30 mg/dL above start

Re-check ratio another time using a lower I:C (lower I:C will increase the size of the bolus)

4-5 hours after CHO bolus:

Suggested Guidelines for I:C Ratio Adjustments

•Make changes in 1 gram increments

If I:C is less than 1:5


If I:C is between 1:5- 1:20


If I:C is between 1:20- 1:50


If I:C is more than 1:50

What should we do?

BG Before Meal

1 hr pp 2 hr pp 3 hr pp 4 hr pp 5 hr pp

Day 1 99 220 181 176 153 151

Day 2 121 277 205 188 181 185

Day 3 1 07 256 230 205 194 183

Breakfast I:C

1:15

Suggested Changes

Change I:C to 1:13

Or bolus for breakfast 20 to 30 minutes before breakfast

Insulin Sensitivity Factor (ISF)

Once you have confirmed basal settings and bolus dosages for carbohydrate, you can evaluate ISF

The goal is for the ISF to return from a BG above target to the target range within 4 hrs of a correction bolus

Calculating ISF

ISF indicates how much (mg/dL) 1 unit of rapid-acting insulin will lower BG

Determine starting point: 1500 or 1800 ÷ TDD (Total Daily Dose) = ISFExample: 1800 ÷ 40 U = 45 ISF

May have more than one ISF for different times of day

Evaluating ISF

What to do When to test• Give a correction dose of

insulin for high BG• Test BG hourly for 4 hours

Recommended Goals

4 hours after bolus• BG in target

3.5 hours after bolus• BG should decrease within

30 mg/dL of target at 3.5 hours for rapid-acting insulin

Suggested Guidelines for ISF Ratio Adjustments

•Make adjustments in 5 mg/dl increments

If ISF is less than 20


If ISF is between 20-

100


If ISF is greater than

100

What should we do?

ISF 1:50 High before correction

1 hour post correction



4hour post correction

Correction #1

350 322 230 199 201

Correction #2

375 335 301 275 242

Correction #3

250 180 165 150 155

Suggested Changes

Change ISF to 1:40

Do You Download?

Look for BG trends Number of BG readings Average BG Site changes – cannula fill Bolus frequency Carbs Bolus vs. basal Frequent alarms (empty cartridge, suspend) Current Pump Settings

Look in the History of the Pump

Bolus Amounts Frequency Type

Basal vs Bolus 50:50 How much insulin need for a prescription

Alarms Prime Suspend

What else do we assess?

Infusion site Change frequency Rotation Adherence Pain or Discomfort Bent Cannula Frequency Look for signs of overuse

Bolus timing and type Combo bolus

Combo Bolus

Also known as a square or dual wave bolus

Used as a bolus to cover slower absorbed meals that contain higher protein and fat content

Such as with meals that include buffets, restaurant dining, and pizza

Need to decide duration and ratio when using

When to use a Combo Bolus?Food Duration Ratio

Fast Food, Movie Popcorn,And high fat desserts

1 hour 50:50

Mexican, Chinese, Italian, Steak dinner, Buffets

2 hour 50:50

Pizza 3 hour 50:50

*These are suggested starting points

Evaluating a Combo Bolus

Do Premeal BG – start trial if BG within normal range (90-120 mg/dl)

Determine carbs give and program combo bolus

Monitor BG hourly to evaluate for up to 6 hours

Did the BG return to within 30 mg/dl of the target range within 6 hours?

The 2 hour BG check

The purpose of the 2 hour check is to determine if the first portion of the bolus was the correct amount to maintain normal BG 2 hours after the meal

If the 2 hour BG is high try a 60:40 split next time continue to make adjustments until the right combination is reached.

If the 2 hour BG is low try 40:60 split next time.

The 4 hour BG check

The purpose of the 4 hour check is to determine if the 2nd portion of the bolus was the correct amount to maintain normal BG 4 hours after the meal

If the 4 hour BG is high increase the amount of insulin given over the extended portion of the bolus

The 6 hour BG check

The purpose of the 6 hour check is to see if the second portion of the bolus was the correct amount of insulin and the right length of time

If the BG was normal at the 4 hour check but high a the 6 hour check the extended portion of the bolus may need to be increased.

Putting it into practice

12 year old male – A1c 10.5%

HCP sends pt to the educator for carb counting review

Has been on pump for 2 years Patient comes in with both parents Parents express concerns and

frustrations accusing child of sneaking food and not bolusing

Patient is quiet and pouty

What things should we assess?

Have orders from HCP that allows you to make dosage adjustments

Review Daily routine – assess carb counting ability.

Download pump or look in history Bolus, bg testing results, site change

frequency Other

Results of Assessment

Found carb counting ability to be adequate, but often guessing amounts

After reviewing pump data we find that the patient has been bolusing for meals and snacks

BG logs reveal that pt is testing frequently as most results are above target range

Basal vs. Bolus reveals that patient is constantly trying to correct bg. Basal is only 30% 0f Total Daily Dose

Plan for 12 year old male Improve Carb Counting accuracy by measuring

portions, reading food labels, and using the smart features on the pump to calculate bolus doses

Praise patient for bolusing and testing frequency

Let him know that he is growing and he just needs more insulin.

Do a 10% increase on basal immediately Instruct family on basal testing and ask them to

send in results in 1 week for needed basal adjustments or make 1 week f/u appointment.

32 yo Female – A1c 8.8%

She works full time and has 3 young children

Both the HCP and patient are frustrated with the poor bg control

She is fearful of lows - hx of severe hypoglycemic event 3 years ago

Has been on pump for 6 years

What things should we assess?

Have orders from HCP that allows you to make dosage adjustments

Review Daily routine Download pump or look in history

Bolus – frequency and timing, bg testing frequency and results, site change frequency and rotation

other

Results of Assessment

Daily routine reveals that life is chaotic and lacks a consistent schedule and as a mom she puts herself last

Dine out frequently Pump download reveals

boluses and bg testing infrequent often only 1-2 per day

Not using the pump bolus calculator features or combo bolus when dining out

Changing site every 4-5 days when cartridge runs out

Has only used abdomen for infusion site area

Plan for 32 yo female

Set reminders on pump to bolus Discuss and instruct pt on benefits of using the

bolus calculating features on the insulin pump including the combo bolus (for dining out)

Discuss the importance of site change frequency and rotation. Suggest she only fill her cartridge with a 3 day supply of insulin. Have pt use a alternate infusion site area and leave abdomen area alone for at least 3 months.

Discuss benefits of a CGM

Presented by Susie Heaton, MS, RD, CDE. Basal rates Insulin to Carbohydrate Ratio (I:C) Insulin...

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Transcript of Presented by Susie Heaton, MS, RD, CDE. Basal rates Insulin to Carbohydrate Ratio (I:C) Insulin...