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Clinical Nutrition 3 > Insulin Pump Therapy Part I > Flashcards

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)

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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”

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3
Q

(T/F) There is long-acting insulin in an insulin pump

A

F

there is only rapid insulin

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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
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5
Q

What does the basal rate aim to cover?

A

For baseline hormone activation, metabolism

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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

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7
Q

What is bolus injection?

A

A spurt of insulin delivered quickly to match carbs or to correct a high BG

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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

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9
Q

What are hybrid closed loop pumps?

A

A sensor which will continuously read BG, then suggest insulin for the patient to administer

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10
Q

Which trial concluded that strict glycemic control in patients with T1DM prevented up to 70% of microvascular complications?

A

DCCT Study

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11
Q

What did the EDIC study conclude?

A

-Strict glycemic control reduced the subsequent risk of a macrovascular event in patients with T1DM

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12
Q

What are the consequences to strict glycemic control?

A

-Hypoglycemia

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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
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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
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15
Q

What is the preferred insulin management for T1DM/

A
  • Basal-bolus insulin therapies

- MDI or Continuous subcutaneous insulin-infusion

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16
Q

If glycemic targets are mot met with MDI, what may be recommended?

A

-Continuous subcutaneous insulin infusion may be considered

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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

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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
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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)
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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
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21
Q

Who is a pump candidate?

A
  • Those with small/precise insulin needs (newborns, children)
  • Hypoglycemia
  • Dawn phenomenon
  • Planning conceptions/pregnancy
  • Gastroparesis
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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
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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
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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
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25
Q

Discuss how insulin pumps may lead to ketoacidosis

A
  • 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)
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26
Q

Discuss the danger of ketoacidosis.How can it be ruled out?

A

-Many symptoms of DKA is similar to just being sick; therefore we must utilize by checking ketones

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27
Q

What is the Tx for DKA?

A

Through hydration and insulin via IV

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28
Q

What are the most common causes of high?

A
  • Miscounted carbs

- Insulin delivery issue at the infusion site

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29
Q

Solution for miscounted carbs within the context of DKA?

A

Do a 24hr diet Hx to assess CHO counting skills

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30
Q

Which issues should be investigated if we suspect there to be insulin delivery issues at the infusion site?

A
  • Infusion set/site issue (i.e. left in > 3days)
  • Insulin pump issue (Forgot last bolus)
  • Personal factors (miscounted CHO)
  • Insulin issues (Inulin expired, cloudy)
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31
Q

How do we correct for high ketones?

A

-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

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32
Q

When ketone blood levels are ______ patient should go to the ER right away

A

> /= 3.0

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33
Q

What is an early sign of DKA?

A
  • Nausea

- Check blood ketone level

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34
Q

Explain why we reduce the insulin injection dosage in pump therapy

A

The pump is so efficient, therefore we need less insulin

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35
Q

What is the reduced injection dose (RID)?

A

Daily injection dose x 0.75

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36
Q

What is the weight dose (WD)?

A

Weight (kg) x 0.5

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37
Q

Knowing the RID and the WD, what is the pump total daily dose (TDD)?

A

RID + WD / 2

-The average of what the “person is taking right now” compared to “what the body actually needs”

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38
Q

Knowing the TDD, what is the Total Daily Basal Dose (DBD)?

A

Pump TDD x 0.50

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39
Q

Knowing the Total DBD, what is the Basal rate (BR)?

A

DBD/24 = BR/hour

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40
Q

Knowing the Pump TDD and the DBD, what is the Daily Bolus dose?

A

Pump TDD - DBD

-What is left over from the basal rate will be our bolus dose

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41
Q

Equation for ICR?

A

Daily Carbs/Daily Bolus Dose

42
Q

What is an alternative equation for the ICR?

A

500 or 480 / TDD

43
Q

Equation for the ISF?

A

100/Pump TDD

44
Q

What is the ISF?

A

The amount of mmol the BG will drop per U of insulin

45
Q

What is basal rate testing?

A

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
Q

(T/F) The basal “pulse” will have an immediate effect on blood glucose

A

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
Q

What is the suggested % change if basal rates need to be adjusted?

A

Start with 10%

48
Q

What are 4 indications that the basal rate is high?

A
  • 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
Q

At what % of TDD may we suspect BR to be too high?

A

When BR is >55% of TDD

50
Q

What are 4 indications that the basal rate is low?

A
  • BG at breakfast is > bedtime BG
  • BG rise between middle of night and at breakfast
  • BG rises when meals are skipped
  • Frequent highs
51
Q

At what % of TDDs may we suspect BR to be too low?

A

<45% of TDD

52
Q

What is active insulin?

A
  • 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
Q

What does the target range of blood glucose tell us?

A

-Provides us the parameter which determined whether a correction bolus is needed

54
Q

What kinds of blood glucose targets exist?

A

Pre-meal target ranges, post-meal, bed-time

55
Q

Daytime glucose target?

A

5.0-6.0

56
Q

Hypo-unawareness?

A

6.0-8.0

57
Q

Pregnancy?

A

4.4-5.0

58
Q

How does FGM and CGM read blood glucose levels?

A

Through interstitial fluid, and not capillary blood

59
Q

What is an example of Flash glucose monitoring (FGM)?

A

-Freestyle Libre

60
Q

How can we continuously see our blood glucose levels with the pump?

A

When CGM is integrated into the pump

61
Q

Wha are three parameters which are important to analyze in pump reports?

A
  • BEAM score
  • Bolus adjustment
  • Basal adjustment
62
Q

What is the BEAM score?

A
  • BEdtime and AM BG levels

- If there is >3-4 mmol/L change between bedtime and am –> we may need to adjust BR

63
Q

If BG is high after a meal, how should the bolus be adjusted?

A

Lower the ICR (Same amount of insulin to cover less amount of CHO, therefore would need more insulin for same amount of CHO)

64
Q

If BG is low after 1-2 hrs after meal, how should the bolus be adjusted?

A

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
Q

If fasting BG is too high, how should we adjust basal?

A

Increase

66
Q

If BG is low 4-5 hrs pc meal, how should we adjust basal?

A

Decrease basal

67
Q

PBG and pre-prandial (AC) BG target?

A

4.0-7.0 mmol/L

68
Q

Pot-prandial (PC) BG targets?

A

5-8 mmol/l or 5-10 mmol/L

69
Q

What is meal excursion?

A

How much blood glucose will rise after a meal

70
Q

What is the meal excursion target?

A

2.2-3.3 mmol/L

Average of 3 mmol/L

71
Q

What does the literature show about using CGM with insulin pump therapy?

A

Resulted in successfully brining A1C into target without increasing episodes of hypoG

72
Q

What did the DIAMOND study suggest about CGM?

A

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
Q

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

A

CGM

74
Q

When assessing blood sugars in pump logs, what is the FIRST think to check?

A

Hypoglycemia is our top priority

We must investigate to see what may have caused the hypos

75
Q

Why is having one low and independant RF for having another?

A

Due to the decrease in counterregulatory hormones (glucagon, cortisol, GH) which are depleted in attempt to counteract the previous hypoglycemic response

76
Q

At which level of blood glucose may risk damaging brain function?

A

When less than 4 mmol/L in patients with diabetes

77
Q

What do we always check first when assessing pump reports, after hypoGs?

A

The basal rate

-By assessing how blood glucose changes at baseline 4 hours after last meal or bolus

78
Q

What are four ways we could investigate hypoglycemia?

A
  • 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
Q

Discuss how correcting hypoG will correct HyperG

A

If we re-allocate the insulin from the hypoG to the hyperG, there will be better blood glucose control

80
Q

How will correcting “over-correcting” lead to desirable weight loss?

A

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
Q

If we realize that there is too much insulin with the basal rate, how do we correct?

A
  • Decrease basal rate by 10%

- However, consider keeping the same for times of day where hypoG is not experienced

82
Q

Why may our basal rate of insulin be higher at midnight compared to 3pm?

A

To counteract the surge of GH and cortisol in the AM, and hopefully we will not wake up with higher BG

83
Q

What are the criteria to do a basal rate ?

A
  • 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
Q

How do we test basal rate?

A
  • 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
Q

When evaluating hyper/hypoG, what must we also intervene on?

A

The behaviour

  • Fear of hypo/hyperG
  • Manual bolusing (to override the pump bc of these fears)
  • Changing sites
  • Testing BG
86
Q

If blood sugar is high, but is not coming down (even if correcting) what should we check?

A

ISF, as we may now need more insulin to drop BG

87
Q

Discuss how the ISF changes if we require more Pump TDD

A
  • 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
Q

Discuss how the ISF changes if we require less PUMP TFF

A
  • 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
Q

When someone takes a correction dose because of a high BG, when should they be back within their target?

A

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
Q

When should a patient test their correction factor?

A
  • 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
Q

When should patients NOT administer a correction dose?

A
  • 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
Q

When may the ISF be too high? (Not enough insulin administered)

A

-When blood sugar ends up 2 mmol/L above target blood sugar after 4 hours

93
Q

When may the ISF be too low? (Too much insulin administered)

A

-When blood sugar ends up >2mmol/L below target blood sugar after 4hrs

94
Q

What should the correction factor do?

A

Bring blood sugar down within 2 mmol/L of target within 5 hours without going to low

95
Q

What is the correction factor?

A
  • 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
Q

(T/F) A low correction FACTOR should be considered before bed

A

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
Q

When may large correction DOSES be required?

A
  • Recall that large correction DOSE means lower ISF (less sensitive, and more insulin administered)
  • Extremely high blood sugar, ketoacidosis, infection, use of prednisone
98
Q

When may lower correction DOSES be required?

A
  • 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
Q

What are the four main causes of hyperglycemia?

A
  • Not enough insulin
  • Too many carbs
  • Stress
  • High intensity (anaerobic) PA or no PA (sedentary)
100
Q

What may be an unsuspecting cause of hyperglycemia?

A

-Taking corticosteroids (prednisone)
-Hydration
Asking QUESTIONS is important to rule out these factors before adjusting the insulin dosages

Clinical Nutrition 3 (30 decks)

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