Insulin Pump Therapy Part I Flashcards
1
Q
What is a basal rate?
A
A continuous 24 hour delivery of insulin that matches the background insulin needs (mimicking the pancreas)
2
Q
Compare and contrast MDI and insulin delivery via a pump
A
- In MDI, they will take long and rapid acting insulin
- In an insulin pump, there is only rapid insulin, which will be titrated to act as “basal” and “bolus”
3
Q
(T/F) There is long-acting insulin in an insulin pump
A
F
there is only rapid insulin
4
Q
How is the basal insulin delivered in insulin pump therapy?
A
- Very small amounts of rapid insulin are released in a pulsatile fashion
- This mimics the pancreas
5
Q
What does the basal rate aim to cover?
A
For baseline hormone activation, metabolism
6
Q
What does bolus injections aim to cover?
A
The rapid insulin will cover the increase in blood glucose in meal excursions
-We can also administer bolus injections to correct blood glucose
7
Q
What is bolus injection?
A
A spurt of insulin delivered quickly to match carbs or to correct a high BG
8
Q
Discuss the advantage of insulin pump therapy
A
It most closely mimics the pancreatic insulin delivery, even more so that intensive insulin injection therapy
9
Q
What are hybrid closed loop pumps?
A
A sensor which will continuously read BG, then suggest insulin for the patient to administer
10
Q
Which trial concluded that strict glycemic control in patients with T1DM prevented up to 70% of microvascular complications?
A
DCCT Study
11
Q
What did the EDIC study conclude?
A
-Strict glycemic control reduced the subsequent risk of a macrovascular event in patients with T1DM
12
Q
What are the consequences to strict glycemic control?
A
-Hypoglycemia
13
Q
Provide 5 advantages of insulin pump therapy
A
- Improved BG control
- Less hypoglycemia
- Prevention of long-term complications
- Convenient, freer lifestyle
- More flexible schedule of eating
14
Q
How does better diabetes management save healthcare costs?
A
- With improved QOL, we know people will manage taking care of themselves. Therefore if we can manage the complications, we will save money.
- 1 day of dialysis = 20k, 1 episode of hypoglycemia =3k
15
Q
What is the preferred insulin management for T1DM/
A
- Basal-bolus insulin therapies
- MDI or Continuous subcutaneous insulin-infusion
16
Q
If glycemic targets are mot met with MDI, what may be recommended?
A
-Continuous subcutaneous insulin infusion may be considered
17
Q
Who may continuous monitoring be offered to?
A
People not meeting their requirements, despite taking adequate measure to wear their devices the majority of time
-Continuous monitoring is very expensive
18
Q
What can pumps do?
A
- Will calculate precise and accurate doses based on several manually inputed factors
- has bolus and a constant basal rate
- The bolus/basal using rapid acting insulin mimics the pancreas and digestion
19
Q
What parameters are included in the insulin pump?
A
- ICR (Insulin:Carb ratio)
- ISF (Insulin sensitivity factor or correction factor)
- IOB (Insulin on board)
20
Q
What is IOB?
A
- Insulin on board
- Will tell us how much insulin is still active in our body
- Prevents insulin stacking and hypoglycemia
21
Q
Who is a pump candidate?
A
- Those with small/precise insulin needs (newborns, children)
- Hypoglycemia
- Dawn phenomenon
- Planning conceptions/pregnancy
- Gastroparesis
22
Q
Which characteristics make good pump candidates?
A
- Patient is able to SMBG
- Responsible, comes to appts
- Capable of uploading the pump
- Count CHOs
- Good judgement
- $$ plan
23
Q
(T/F) Insulin pumps do all the work, and are a cure for diabetes
A
- Do NOT do all the work, and therefore we cannot set the expectations that pumps are the cure
- These are useful TOOLS which still require skills and management on behalf of the patient
24
Q
What are some disadvantages to insulin pump therapy?
A
- Attachment 24 hrs/day
- Ketoacidosis
- Site issues
- Expenses
- Currently only covered for pediatrics in Quebec
25
Discuss how insulin pumps may lead to ketoacidosis
- If the pump is taken off, there will only be rapid acting insulin in our body.
- Therefore, if the pump is removed for longer than 4 hours, there will be NO insulin remaining in the body
- No insulin means that we will have an episode of ketoacidosis (insulin doe not suppress the flux of lipolysis)
26
Discuss the danger of ketoacidosis.How can it be ruled out?
-Many symptoms of DKA is similar to just being sick; therefore we must utilize by checking ketones
27
What is the Tx for DKA?
Through hydration and insulin via IV
28
What are the most common causes of high?
- Miscounted carbs
| - Insulin delivery issue at the infusion site
29
Solution for miscounted carbs within the context of DKA?
Do a 24hr diet Hx to assess CHO counting skills
30
Which issues should be investigated if we suspect there to be insulin delivery issues at the infusion site?
- Infusion set/site issue (i.e. left in > 3days)
- Insulin pump issue (Forgot last bolus)
- Personal factors (miscounted CHO)
- Insulin issues (Inulin expired, cloudy)
31
How do we correct for high ketones?
-After confirming that blood ketones are elevated by using ketone strips, more insulin than normal will be required to bring the ketone level back to normal
32
When ketone blood levels are ______ patient should go to the ER right away
>/= 3.0
33
What is an early sign of DKA?
- Nausea
| - Check blood ketone level
34
Explain why we reduce the insulin injection dosage in pump therapy
The pump is so efficient, therefore we need less insulin
35
What is the reduced injection dose (RID)?
Daily injection dose x 0.75
36
What is the weight dose (WD)?
Weight (kg) x 0.5
37
Knowing the RID and the WD, what is the pump total daily dose (TDD)?
RID + WD / 2
| -The average of what the "person is taking right now" compared to "what the body actually needs"
38
Knowing the TDD, what is the Total Daily Basal Dose (DBD)?
Pump TDD x 0.50
39
Knowing the Total DBD, what is the Basal rate (BR)?
DBD/24 = BR/hour
40
Knowing the Pump TDD and the DBD, what is the Daily Bolus dose?
Pump TDD - DBD
| -What is left over from the basal rate will be our bolus dose
41
Equation for ICR?
Daily Carbs/Daily Bolus Dose
42
What is an alternative equation for the ICR?
500 or 480 / TDD
43
Equation for the ISF?
100/Pump TDD
44
What is the ISF?
The amount of mmol the BG will drop per U of insulin
45
What is basal rate testing?
In order to ensure that we have the right basal rate, we want to assess blood glucose 4 hours after last CHO or correction bolus. If BG rises, we need a greater BR, if BG lowers, we need a lesser BG
46
(T/F) The basal "pulse" will have an immediate effect on blood glucose
F, will likely not have an effect until 2 hours later. Therefore, to critique issues with basal dosages, we must work 2-3 hours behind (i.e. reduce basal insulin 2 hours before the offending hypo or hyperglycemia)
47
What is the suggested % change if basal rates need to be adjusted?
Start with 10%
48
What are 4 indications that the basal rate is high?
- BG is low after breakfast
- BG goes low if meals are skipped, or >5 hours without eating a meal
- BG often low after meals
- Frequent lows
49
At what % of TDD may we suspect BR to be too high?
When BR is >55% of TDD
50
What are 4 indications that the basal rate is low?
- BG at breakfast is > bedtime BG
- BG rise between middle of night and at breakfast
- BG rises when meals are skipped
- Frequent highs
51
At what % of TDDs may we suspect BR to be too low?
<45% of TDD
52
What is active insulin?
- The insulin still active in the body with the ability to lower BG
- Originates from the last bolus dose
- Knowing our active insulin will help us prevent insulin stacking
- Insulin remains active for about 4-5 hours in the body
53
What does the target range of blood glucose tell us?
-Provides us the parameter which determined whether a correction bolus is needed
54
What kinds of blood glucose targets exist?
Pre-meal target ranges, post-meal, bed-time
55
Daytime glucose target?
5.0-6.0
56
Hypo-unawareness?
6.0-8.0
57
Pregnancy?
4.4-5.0
58
How does FGM and CGM read blood glucose levels?
Through interstitial fluid, and not capillary blood
59
What is an example of Flash glucose monitoring (FGM)?
-Freestyle Libre
60
How can we continuously see our blood glucose levels with the pump?
When CGM is integrated into the pump
61
Wha are three parameters which are important to analyze in pump reports?
- BEAM score
- Bolus adjustment
- Basal adjustment
62
What is the BEAM score?
- BEdtime and AM BG levels
| - If there is >3-4 mmol/L change between bedtime and am --> we may need to adjust BR
63
If BG is high after a meal, how should the bolus be adjusted?
Lower the ICR (Same amount of insulin to cover less amount of CHO, therefore would need more insulin for same amount of CHO)
64
If BG is low after 1-2 hrs after meal, how should the bolus be adjusted?
Increase the ICR (Same amount of insulin to cover more CHOs, therefore we would need less insulin to cover the same amount of CHOs)
65
If fasting BG is too high, how should we adjust basal?
Increase
66
If BG is low 4-5 hrs pc meal, how should we adjust basal?
Decrease basal
67
PBG and pre-prandial (AC) BG target?
4.0-7.0 mmol/L
68
Pot-prandial (PC) BG targets?
5-8 mmol/l or 5-10 mmol/L
69
What is meal excursion?
How much blood glucose will rise after a meal
70
What is the meal excursion target?
2.2-3.3 mmol/L
| Average of 3 mmol/L
71
What does the literature show about using CGM with insulin pump therapy?
Resulted in successfully brining A1C into target without increasing episodes of hypoG
72
What did the DIAMOND study suggest about CGM?
Even with just CGM, we may be able to have between blood glucose control as it can tell us if our BG is titrating up or down
-Will also result A1C reduction without increasing hypoG
73
In adults with T1DM and an A1C at or above target, regardless of insulin delivery method used ____ will help improve or maintain A1C without increasing hypoglycemia
CGM
74
When assessing blood sugars in pump logs, what is the FIRST think to check?
Hypoglycemia is our top priority
| We must investigate to see what may have caused the hypos
75
Why is having one low and independant RF for having another?
Due to the decrease in counterregulatory hormones (glucagon, cortisol, GH) which are depleted in attempt to counteract the previous hypoglycemic response
76
At which level of blood glucose may risk damaging brain function?
When less than 4 mmol/L in patients with diabetes
77
What do we always check first when assessing pump reports, after hypoGs?
The basal rate
| -By assessing how blood glucose changes at baseline 4 hours after last meal or bolus
78
What are four ways we could investigate hypoglycemia?
- Is the patient exercising more than usual?
- Is the patient taking less carb than normal?
- Is the patient taking too much insulin?
- Is the patient consuming alcohol?
79
Discuss how correcting hypoG will correct HyperG
If we re-allocate the insulin from the hypoG to the hyperG, there will be better blood glucose control
80
How will correcting "over-correcting" lead to desirable weight loss?
When people experience a hypoG, they will go into "survival mode" and consume everything in site, leading to potential weight gain. if we can intervene, then they may see some weight-loss.
81
If we realize that there is too much insulin with the basal rate, how do we correct?
- Decrease basal rate by 10%
| - However, consider keeping the same for times of day where hypoG is not experienced
82
Why may our basal rate of insulin be higher at midnight compared to 3pm?
To counteract the surge of GH and cortisol in the AM, and hopefully we will not wake up with higher BG
83
What are the criteria to do a basal rate ?
- BG is between 5.6-8.3
- Last carb or correction bolus was 4hrs ago
- Last meal was low fat
- No hypoG in last 5hrs
- No extra exercise
84
How do we test basal rate?
- When criteria is met, have patient skip a meal (can have water, but no caffeine) and then evaluate for a fall or rise of more than 1.7 mmol/L over 4-5 hours
- Have patient test their BG every 4-5 hours
85
When evaluating hyper/hypoG, what must we also intervene on?
The behaviour
- Fear of hypo/hyperG
- Manual bolusing (to override the pump bc of these fears)
- Changing sites
- Testing BG
86
If blood sugar is high, but is not coming down (even if correcting) what should we check?
ISF, as we may now need more insulin to drop BG
87
Discuss how the ISF changes if we require more Pump TDD
- Recall that ISF = 100/Pump TDD
- If we increase our overall insulin needs, we are "less insulin sensitive" and per units of insulin, our BG will drop less
- We need more overall insulin to drop blood glucose levels
88
Discuss how the ISF changes if we require less PUMP TFF
- Recall that ISF = 100/Pump TDD
- If we decrease our overall insulin needs we are more insulin sensitive, and therefore need less insulin to drop our BG
- We will require less insulin for the same drop in BG
89
When someone takes a correction dose because of a high BG, when should they be back within their target?
Within 4 hours
-If not back within 4 hours may either need to increase basal rate, increase Pump TDD and ISF consequently decreases (patient now required more insulin)
90
When should a patient test their correction factor?
- When blood sugar is 11 mmol/L
- When it has been at least 3 hrs since they last ate
- It has been at least 4 hrs since the last bolus
91
When should patients NOT administer a correction dose?
- If their highs often come down on their own
- If they are having frequent or severe low blood sugars
- If pending exercise will lower it
92
When may the ISF be too high? (Not enough insulin administered)
-When blood sugar ends up 2 mmol/L above target blood sugar after 4 hours
93
When may the ISF be too low? (Too much insulin administered)
-When blood sugar ends up >2mmol/L below target blood sugar after 4hrs
94
What should the correction factor do?
Bring blood sugar down within 2 mmol/L of target within 5 hours without going to low
95
What is the correction factor?
- The ISF
- The amount of mmol of blood glucose which will be lowered by 1 U of insulin
- A large correction DOSE is a lower ISF
- A small correction DOSE is a higher ISF
96
(T/F) A low correction FACTOR should be considered before bed
F
A low correction factor, or a low ISF ( more insulin is being administered) which may risk night-time hypoglycemia. -Consider using a large correction factor (high ISF) near bedtime and reduce the size of correction boluses
97
When may large correction DOSES be required?
- Recall that large correction DOSE means lower ISF (less sensitive, and more insulin administered)
- Extremely high blood sugar, ketoacidosis, infection, use of prednisone
98
When may lower correction DOSES be required?
- Recall that a lower correction DOSE means a higher ISF (more sensitive, and less insulin administered)
- Weight loss, increased activity or at night-time
99
What are the four main causes of hyperglycemia?
- Not enough insulin
- Too many carbs
- Stress
- High intensity (anaerobic) PA or no PA (sedentary)
100
What may be an unsuspecting cause of hyperglycemia?
-Taking corticosteroids (prednisone)
-Hydration
Asking QUESTIONS is important to rule out these factors before adjusting the insulin dosages
