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Clinical Nutrition 3 > Insulin Pump Therapy Part II > Flashcards

Insulin Pump Therapy Part II Flashcards

1
Q

Explain why some corrections are normal for the insulin pump

A

Sometimes will will have unplanned exercise, therefore if our pump suggests a certain amount of insulin, we may decide to “correct” and take less

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2
Q

Why is it important to address hypos, especially in the elderly?

A
  • many elderly are scared of hyperG

- May have hypoG unawareness, which may predispose them to car accidents, falling, injuries etc.

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3
Q

What are some potential causes of going hyper PC lunch?

A
  • Issues with ICR (with counting CHOs, or with basal rate)
  • CHO counting issues
  • Problem with injection sites/malabsorption of insulin
  • Overriding insulin - taking less
  • Reaction from hypoglycemia
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4
Q

What is insulin on board?

A

The calculation which tells us how much insulin is still active in our body from previous bolus doses

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5
Q

How long does it usually take to metabolize insulin?

A

3.5-5 hours with 4 hours on average

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6
Q

Can there be more than one basal rate per day?

A

Yes

-However, nor more than 5-6 different basal rates/day

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7
Q

When will basal rates differ?

A
  • Insulin resistance and sensitivity

- Scheduled PA

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8
Q

What is the ICR?

A

How many grams of CHO 1 unit of insulin will cover

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9
Q

What is important to consider prior to adjusting the ICR?

A

We need to make sure that basal rates are accurate prior to adjusting the ICR

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10
Q

When is it OK for a patient test their ICR?

A
  • When they have not had a low blood sugar or hypoglycemia in the last 4hrs
  • When their blood sugar is between 5-9 mmol/L before a meal and they have not eaten in the last 3 hrs or bolus in past 4 hrs
  • They have consumed a low-fat meal which they can predict carb count for
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11
Q

What is the first step to test ICR?

A

-Eat enough carbs to challenge your ratio

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12
Q

What is the second step to test ICR?

A

-Test blood sugar, enter the grams of CHO into your pump and take the carb bolus no more than 20 mins before eating

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13
Q

What is the third step to test ICR?

A

-Test blood sugar 2 hours after the meal and 4 hours after the meal

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14
Q

When is the IC adequate?

A
  • When blood sugar rises 2-3 mmol/L after eating AND

- 4-5 hours after eating, blood sugar is within 1.7 mmol/L of pre-meal blood sugar

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15
Q

(T/F) If BG rises more than 2-3 mmol/L 2 h after eating we require a larger ICR

A

F

We need a smaller ICR. This means that we require more insulin per same G of CHO, thus requiring overall more insulin to bring down blood glucose levels

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16
Q

If blood sugar rises by LESS than 2 mmol/L 2 hours after eating, how should we adjust ICR?

A

We should INCREASE the ICR ratio. This means that we will require less insulin per same G of CHO, thus requiring less amount of insulin to avoid undesirable decreases in blood glucose

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17
Q

What are some reasons for unexplained highs/lows? (I.e. if we do not need to adjust ICR/Basal rate)

A
  • CHO count not accurate
  • Meal unusually high or low GI meal
  • Higher fat/protein meal
  • Less active
  • Recent hypoG
  • Improper basal rates
  • More stressed
  • When was bolus taken?
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18
Q

What is an unsuspecting reason for hyper or hypo G if all paramaters appear OK?

A

Issue of digestion of fats and proteins on the action of insulin

  • Recall that we have RAPID acting insulin in the insulin pump, where its course of action typically terminates after 2 hours
  • Fat and proteins, depending of on the meal could take up to 8 hours to digest
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19
Q

Describe the two phases of the insulin secretion from the pancreas in a healthy individual

A

1) A large surge of insulin for the initial CHO release and 2) Small pulses to cover the rest of the digestion
- -> Therefore, we need to program the insulin pump to it can accomodate for the pulsitility required for the differing digestibility of meals

20
Q

What happens when we take an injection of rapid insulin?

A
  • We are only mimicking phase one of the insulin secretion
  • We are missing the insulin which is required for the longer, digestion process
  • This often occurs in mixed meals
21
Q

What is a key advantage of the insulin pump?

A

We can titrate our insulin needs to only to the CHO amount, but also to the digestion based on the different composition and fat/protein content of our meals

22
Q

If someone is eating a very high fat/protein meal and has rapid-acting insulin injection, what can we anticipate?

A

The insulin will work faster than the food is digested, causing hypoglycemia

  • If we see low BG 1-2 hours after a meal, we may suspect that the food didn’t get there in time to be covered by the insulin
  • Then once the food finally gets absorbed, we will see a HIGH
23
Q

What are the two types of advanced bolusing?

A

1) Dual-wave/Combo

2) Square wave/extended

24
Q

What is the dual-wave/combo?

A
  • A percentage of insulin is delivered immediately and the remainder over an extended period of time
  • 50% “hit” of insulin and then the other 50% delivered through pulses over time
  • Would be ideal for high fat/high carb meals which have CHO
25
Q

What is the square wave/extended?

A

Delivers insulin over a set amount of time decided by the user

  • Pulses of insulin over a certain amount of time, without any up-front
  • Would be ideal for gastroparesis, low glycemic meals
26
Q

A client is consuming a pizza (high fat, high carb, high protein) with 60 g of CHO. Which type of bolus do you recommend? If their ICR is 1:14, calculate how many insulin units they require with the type of bolus selected.

A
  • Dual-wave
  • 1/14 x 60g CHO = 4.3 units of insulin
  • Try 50% up front and 50% over 2 hours
  • Therefore administer 2.15U now and 2.15U over 2 hours
  • Then, test BG every hour to see how this works and can adjust the percentage as well as the duration.
27
Q

How do we know if we have selected the correct type of advanced bolus and dosing?

A

-If BG doesn’t drop after the meal and doesn’t rise before the meal

28
Q

What is the mechanism which causes hypoglycemia when alcohol is consumed?

A

The liver is will normally perform gluconeogenesis, however if it is busy metabolizing alcohol it will stop producing glucose.
–> However, if we eat with alcohol, glucose from diet may be OK

29
Q

In someone who would like to consume alcohol, or who may temporarily need less insulin, how can we manipulate their pump?

A

With temporary basal rates (TBR)

30
Q

What is TBR?

A

A % increase or decrease in BR over a set time period in increments of 30 minutes

31
Q

Within the context of alcohol consumption, how should we adjust TBR?

A

-Try a TBR of 70% (or a decrease of 30%) over 4-6 hours

32
Q

What else can TBR be used for?

A
  • Address transient increases or decreases in insulin needs

- Exercise, sickness/stress, food, cortiocsteroids

33
Q

What is important to consider when adjusting TBR?

A

That the basal rate we are getting now, will affect our BG 2 hours later. Therefore, we must think 2 hours ahead

34
Q

In exercise, how should as adjust TBR?

A
  • Decrease BR ideally about 60-90 minutes prior to activity, during and extended afterwards
  • This will allow us to have less insulin in our body when we exercise, preventing hypoG
  • Therefore TBR are useful when we can plan ahead
35
Q

What is TBR preferred over?

A
  • Removing/disconnecting the pump (suspending the pump)

- If insulin is stopped, in 2-3 hours our blood glucose will be high

36
Q

If we suspend our insulin for >1 hour, but were NOT active during this one hour, how should we replace insulin?

A

-Replace with standard dose

37
Q

If we suspend our insulin for ?1 hour and we WERE active during that time, how should we replace insulin?

A

Replace with 50% of standard dose

38
Q

If there is a 30 minute suspension of insulin, how can we suspect our blood glucose to act?

A

Will have a 3hr post rise

39
Q

If fever, how should patient adjust their TBR?

A
  • Increase 25% over 24 hours

- More insulin to combat increased blood glucose during a state of stress

40
Q

During aerobic exercise, how will our BG react?

A

Will tend to go DOWN

41
Q

During anaerobic exercise, how will our BG react?

A

Will tend to go UP

42
Q

What are X-carbs?

A

How much glucose our muscles use during exercise

43
Q

What may also impact BG in terms of exercise?

A

Whether they are typically active or inactive

–> Those who are inactive will likely have a greater rise or drop in blood sugar

44
Q

If exercise is within 60-90 minutes of a bolus, how should we adjust the bolus?

A

Decrease the bolus if exercise in anticipated

-We may adjust TBR, bolus or both

45
Q

The longer the exercise and the greater intensity may require us to adjust our insulin in what way?

A

-May need to adjust both bolus and TBR insulin

46
Q

How can good hydration impact the diabetic patients?

A
  • Can help control BG
  • Can help prevent DKA
  • Hydration is key
47
Q

List the order of how we should review pumps

A
  • Address HypoG
  • Assess BR
  • Assess parameter: ICR and ISF
  • CHO counting
  • Targets and acting time
  • Sites, rotation, infusion sites
  • Exercise, ketones, sick days, menstruation
  • Behaviour, fears
  • We MUST ask questions, and ask them what they want to focus on
  • Be encouraging

Clinical Nutrition 3 (30 decks)

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