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Clinical 3 > Insulin pumps > Flashcards

Insulin pumps Flashcards

1
Q

How often should infuse sets be changed?

A

every 2-4 days

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2
Q

Which infusion set is more suitable for athletes? Why?

A

Angled- move with the skin

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3
Q

what type of insulin is used in insulin pumps?

A

rapid

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4
Q

Do we need long acting insulin when we use pumps/

A

no

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5
Q

What is the purpose of bolus?

A

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

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6
Q

benefits of insulin pumps

A
  • mimics pancreas pretty closely
  • Strict glycemic control in patients with type 1 diabetes prevents up to 70% of microvascular complications, particularly retinopathy, neuropathy and nephropathy! (DCCT study) and Strict glycemic control reduced the subsequent risk of a cardiovascular event (CV) (EDIC study)
  • reduced A1C
    — Improved BG control
    — Less hypoglycemia
    — Prevention of long-term complications
    — Convenient freer lifestyle
    — Flexibility schedule and eating
    — Improved matching of I delivery to body needs
    — Improved balancing w exercise
    — More precise insulin delivery (0.025u)
    — Less injections (every 2-3 days)
    — Use of only 1 insulin
    — Advance bolus features
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7
Q

what is the prefered insulin management regimens for adults with type 1 diabetes.

A

Basal-bolus insulin therapies (i.e. multiple daily injections or continuous subcutaneous insulin infusion)

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8
Q

— Pumps can calculate precise accurate doses based on

A 
—ICR
— ISF (CF)
—IOB
— targets
— Bolus types: mimic pancreas and digestion 
— Constant BR (and no long-acting I)
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9
Q

what are Hybrid closed loop pumps

A

calculates and delivers insulin- this is a pump with CGM (blood glucose sensor)

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10
Q

Who is a Pump Candidate?

A 
— Small insulin needs as pumps can deliver veery small doses
— Hypoglycemia unawareness or nocturnal hypo
— Dawn Phenomenon 
—Planning conception and /or pregnancy
—Gastroparesis (without pump: when food is finally digested, insulin is already gone->high blood sugar) /or pregnancy
— Shift work
— Frequent travel
— Desire better control less injections
— Now T2DM
— Exercise regularly, athlete
— Often hospitalized
— Not reaching BG targets- elevated A1C
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11
Q

Pump Candidates Need to be:

A 
— Patient is SMBG- ready to do frequent testing
— Responsible, comes to appts
— Capable of uploading the pump
— Count carbohydrates
— Good judgement : understand sick
day management
— \$\$ plan
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12
Q

Pump disadvantages

A 
— Attachment 24 hrs/d
— Ketoacidosis
— Site issues
— Acceptance (by others) 
— Expenses
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13
Q

What is the blood ketone level that requires ER

A

> 3

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14
Q

__ is an early sign of DKA, if feeling __ check for ketones.

A

Nausea is an early sign of DKA, if feeling sick check for ketones.

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15
Q

Pump Start- initial pump settings- how to calcualte pump TDD

A

— Reduced injection dose: daily injection dose x 0.75 = reduced dose (A)
— Weight dose: kg x 0.53 = wt dose (B)
— Pump total Daily Dose: (A + B) / 2= Pump TDD

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16
Q

How to calculate basal rate?

A

— Total Daily Basal Dose: Pump TDD x 50% (occ.40%) =Daily Basa lDose
— Basal Rate (BR): Daily Basal Dose/24= hourlyBR

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17
Q

How to calculate bolus dose

A

Pump TDD – Daily Basal Dose =

Daily Bolus Dose

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18
Q

how to calculate insulin carb ratio

A

Daily Carbs/Daily Bolus Dose= ICR
or
450/ TDD and-or 5.7 x weight (kg)/TDD

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19
Q

how to calculate ISF

A

Insulin Sensitivity Factor(ISF):
100/pumpTDD
or (120-80) / TDD (sometimes, a range is used, but usually its just 100)

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20
Q

How to test basa; rate

A

— Blood Glucose (BG) between 5.6-8.3 (5-10)
— Last carb or correction bolus was 4hrs ago
— Last meal was low fat meal
— No hypoglycemia in the last 5 hrs
— BG / hr (except night BR)
— Skip meal (water, no caffeine)
— A fall or rise of no more 1.7mmol/L (2.0) over 4-5hrs
— (or wear a sensor!!)

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21
Q

which insulin dose would u adjust if u have a trend of having low BG at 10am?

A

you would adjust the 8am insulin dose for the next day

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22
Q

When should you check your glucose during three basal test periods

A

Overnight: bedtime, 2am waking
Breakfast to afternoon: every 1-2h
Afternoon to bedtime: every 1-2h

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23
Q

How much should be the change in basal rate and when should it be initiated?

A

— Always start change 2-3 hours before the rise or fall of BG
— Start with 10% change

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24
Q

Signs of high basal rate (needs to be lowered)

A

— BG is low AC breakfast (no bolus during the night)
— BG goes low if skip meal or > 5hrs
— BG often low AC meals
— Frequent lows and BR total >55% of TDD

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25
Q

Signs of low basal rate (needs to be increased)

A

— BG breakfast >HS BG
— BG rises between middle of the night and breakfast
— BG rises when skip meal
— Frequent highs and BR total <45% of TDD

26
Q

rapid insulin is in the body for _` hours

A

rapid insulin is in the body for 3-5 hours

27
Q

What is the time frame for active insulin and why do we need to tell clients about it?

A

— Insulin still active in the body with the ability to lower glucose (previous bolus)
— Helps to prevent insulin stacking
— 4-5 hours adults

28
Q

What is the target range? What is it used for?

A

blood glucose values- a range
used to determine if a correction bolus is needed
Pre-meal target ranges, post- meal, bedtime
Ex: daytime: 5.0-6.0
Hypo-unawareness: 6.0-8.0
Pregnancy 4.4-5.0

29
Q

which values does the client need to put into the pump?

A
  • insulin carb ratio
  • BG before the meal
  • grams of carbs
30
Q

Tips for analyzing pump reports

A

we always start with the basal rate- it’s the most important thing

— BEAM score
-Bedtime and am
-If go to bed within target and wake up within target-> don’t change basal
But,
-if > 3-4mmol/L change between bedtime and am ->significant

— Bolus adjustment

  • if BG high after a meal -> lower ICR
  • if BG low 1-2 hrs pc meal -> increase ICR

— Basal adjustment

  • if fasting or pre-meal too high -> increase basal
  • if low 4-5 hrs pc meal-> decrease basal
31
Q

Blood Glucose Targets:
— FBG and pre-prandial(AC):
— Post-prandial (PC):

A

— FBG and pre-prandial(AC): 4.0-7.0 mmol/L
— Post-prandial (PC): 5-8mmol/L or
5-10mmol/L

32
Q

WHat are meal excursions

A

— How much can blood glucose rise after a meal?
— Average: 3mmol/L
— (2.2-3.3 mmol/L)

33
Q

what is the target time in range?

A

70%

34
Q 
Case Study: Nick
22 y.o Male
University student
A1C 8.4%
Wt:79kg, ht: 175.5cm
BP 102/66
OmniPod pump
Full-time student and working part-time (weekends) 
Forgot his food journal...
Has hypoGL in the morning and hyperGL in the afternoon
Solution?
A

— Decrease Hypos will likely lead to less Hypers
Quesitons to ask: — When was the last time BR was reviewed? — When is he exercising? — Alcohol? — Enough Carbs? — Over correcting (too much insulin) — Any changes: weight, schedule, life? — How is he correcting the lows?

— Decrease Basal rate :
— 00:00 – 03:00 : 0.70u/hr (decrease)
— 03:00 – 08:00: 0.9u/hr (decrease)
— 08: 00 – 15:00: 0.5u/hr (keep the same) 
— 15:00 – 00:00 : 0.70u/hr (decrease)
— 10% decrease (0.72u so round down)
— Maybe change pattern times
- his hypos are due to BR being to high
— Decrease Hypos will likely lead to less Hypers
35
Q

What do you test 1st and 2nd in terms of insulin correction

A
  • 1st basal rate

- 2nd ISF (CF)

36
Q

how long does it take for insulin to start decreasing blood sugar>

A

insulin will start decreasing blood sugar 1-2h after the injection
wait 2 hours to see a result
but for it to actually have an impact-> 4h

37
Q

When to test the correction factor?

A
  • Your blood glucose is > 11 mmol/l
  • You have not taken a meal bolus or correction bolus for at least 4 hours
  • You have not eaten any food for the last 4 hours
38
Q

steps for testing correction factor

A

1 | administer your correction dose
2 | do not eat for 4 hrs unless your sugar goes low
3 | test blood sugar every hour for 4 hrs

39
Q

when not to use a correction dose

A

1 | if your high #’s often come down on their own
2 | if you are having frequent or severe low blood sugars
3 | when pending exercise will lower it

40
Q

what are the signs of high ISF?

A

your blood sugar ends up 2 mmol/L above your target blood sugar range after 4 hrs

41
Q

what are the signs of low ISF?

A

your blood sugar ends up 2 mmol/L below your target blood sugar range after 4 hrs

42
Q

how to town that you have perfectly corrected your ISF?

A

repeat the test on a different day until a correction factor consistently brings your blood sugar within 2 mmol/L of your target by 5 hrs without going low

43
Q

bedtime correction factor tip

A

Be careful when correcting high readings before bed. Consider the use of a larger correction factor near bedtime to reduce the size of correction boluses and lessen the risk of night lows. Consider setting an alarm and checking your blood sugar.`

44
Q

when do we need larger correction boluses?

A

A larger correction dose of insulin (lower ISF) may be needed for extremely high blood sugar, ketoacidosis, an infection, pre-menstrual periods, or the use of prednisone.

45
Q

when do we need to lower our correction factors?

A

Weight loss and increased activity will lower your insulin needs, leading to a lower correction dose of insulin (higher
ISF).*

46
Q

signs your basal rates need to be changed:

A

 If your correction factors vary significantly throughout the day, your basal rates likely need to be changed.

47
Q

— Pt has a trend of going low after lunch

— What are the potential causes?

A 
ICR, ISF (too much insulin)
Carb counting issues
Overriding (not agreeing with pump and giving more insulin) 
Physical activity
Alcohol consumption
48
Q

when to test insulin:carb ratio?

A

 you have not had a low blood sugar or hypoglycemia symptoms in the last 4 hrs
 your blood sugar is between 5-10 mmol/L before a meal and you have not eaten in the last 3 hrs or given yourself a bolus in the past 4 hrs
 you are eating a low fat meal that you can reasonably predict the carb content for – try to avoid mixed meals (i.e. casseroles, pasta dishes)

49
Q

3 steps for testing your insulin:cho ratio:

A

1 | eat enough carbs to challenge your ratio (grams of carbs should be around 1/2 your weight in lbs)
2 | test your blood sugar, enter the grams of carbs into your pump and take the carb bolus no more than 20 min before eating
3 | test your blood sugar 2 hours after the meal, and 4 hours after the meal

ideally after 4h your BG should be back to starting point

50
Q

your i:c ratio is adequate if:

A

 your blood sugar rises 2 - 3 mmol/L 2 hrs after eating

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

51
Q

what is the outcome of the test when i:c is to high?

A

if your blood sugar rises by more than 2-
3mmol/L 2 hours after eating:
 you need to use a smaller i:c ratio to give more insulin (decrease the grams of carbs in the ratio)

52
Q

what is the outcome of the test when i:c is to low?

A

if your blood sugar rises by less than 2
mmol/L 2 hours after eating:
 you need to use a larger i:c ratio to give less insulin (increase the grams of carbs in the ratio)

53
Q

reasons for unexpected BG highs/lows?

A

 was the carb count accurate (or close enough)?
 was the meal an unusually high or low glycemic index meal? (ask your educator about using a combination bolus)
 was it a higher fat or protein meal than usual?
 were you more or less active than usual that day?
 did you have any recent hypoglycemia?
 are your basal rates set properly?
 was the bolus taken early enough before eating?
 were you more or less stressed that day?

54
Q

what is insulin on board? when/why is it important?

A

Insulin on Board (IOB) is the calculation that tells you how much insulin is still active in your body from previous bolus doses.
- When correcting: check insulin on board
to avoid insulin stacking

55
Q

Name and describe types of advanced bolusing

A

Dual wave/ Combo: A percentage of insulin delivered immediately and the remainder over an extended period of time.
— Square wave/ extended: Delivers insulin over a set amount of time decided by the user.
- used in cases like gastroparesis when there is a consistently long digestion since everything is digested slowly, we administer small doses over longer periods of time

56
Q

Calculate the amount of carbs:
Ex : 2 slices of a large all dressed pizza: 60g
— Which bolus to use?

A

— 1:14g, 60g pizza = 4.3 u
— First time trying advance bolusing (dual/combo) so try: 50% up front and 50% over 2 hrs:
- 2.15u now and 2.15u delivered over 2 hrs
— Test BG every hour to see how this works and can adjust the percentage as well as the duration
- If BGs doesn’t drop after the meal and doesn’t rise before the next meal it worked!

57
Q

what is temporary basal rate (TBR)?

A

if long-acting insulin is injected- it is going to be in our body for a loooong time and nothing can be done with this
A Temporary Basal Rate (or “temp basal”) is an insulin pump feature which allows you to override your current active basal rate in order to add or subtract a specified amount of insulin from each basal dose, for a specified period of time.
TBR is used for:
- exercise
- sickness/stress food
- alcohol consumption

58
Q

how would you use TBR for exercise?

A

decrease BR ideally about 60- 90 mins prior to activity, during and extended afterwards
— Better then the pumpremoving/disconnecting
— Suspending BR (if >1hr replace missed insulin but if active during that time replace 50%) 30 mins suspension= 3hr post rise
— Decide whether TBR or adjust the bolus or both!
— Exercise within 60-90 mins of a bolus- decrease the bolus
— The longer the exercise and the greater the intensity may need to adjust both

59
Q

how would you use TBR for sickness?

A

Increase BR for 24 hrs ex. Have a fever increase 25% for 24hrs

60
Q

Steps/thinking process of Reviewing Pumps

A
  • Address hypoglycemia
  • Assess BR
  • Parameters: ICR and ISF
  • Carb counting
  • Targets and Acting time
  • Sites, rotation, infusion sets
  • Troubleshooting : exercise, ketones, sick days, menstruation
  • Behaviour
  • Ask Questions!

Clinical 3 (17 decks)

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