Insulin pumps Flashcards
How often should infuse sets be changed?
every 2-4 days
Which infusion set is more suitable for athletes? Why?
Angled- move with the skin
what type of insulin is used in insulin pumps?
rapid
Do we need long acting insulin when we use pumps/
no
What is the purpose of bolus?
a spurt of insulin delivered quickly to match carbs or to correct a high BG
benefits of insulin pumps
- 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
what is the prefered insulin management regimens for adults with type 1 diabetes.
Basal-bolus insulin therapies (i.e. multiple daily injections or continuous subcutaneous insulin infusion)
Pumps can calculate precise accurate doses based on
ICR ISF (CF) IOB targets Bolus types: mimic pancreas and digestion Constant BR (and no long-acting I)
what are Hybrid closed loop pumps
calculates and delivers insulin- this is a pump with CGM (blood glucose sensor)
Who is a Pump Candidate?
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
Pump Candidates Need to be:
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
Pump disadvantages
Attachment 24 hrs/d Ketoacidosis Site issues Acceptance (by others) Expenses
What is the blood ketone level that requires ER
> 3
__ is an early sign of DKA, if feeling __ check for ketones.
Nausea is an early sign of DKA, if feeling sick check for ketones.
Pump Start- initial pump settings- how to calcualte pump TDD
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
How to calculate basal rate?
Total Daily Basal Dose: Pump TDD x 50% (occ.40%) =Daily Basa lDose
Basal Rate (BR): Daily Basal Dose/24= hourlyBR
How to calculate bolus dose
Pump TDD – Daily Basal Dose =
Daily Bolus Dose
how to calculate insulin carb ratio
Daily Carbs/Daily Bolus Dose= ICR
or
450/ TDD and-or 5.7 x weight (kg)/TDD
how to calculate ISF
Insulin Sensitivity Factor(ISF):
100/pumpTDD
or (120-80) / TDD (sometimes, a range is used, but usually its just 100)
How to test basa; rate
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!!)
which insulin dose would u adjust if u have a trend of having low BG at 10am?
you would adjust the 8am insulin dose for the next day
When should you check your glucose during three basal test periods
Overnight: bedtime, 2am waking
Breakfast to afternoon: every 1-2h
Afternoon to bedtime: every 1-2h
How much should be the change in basal rate and when should it be initiated?
Always start change 2-3 hours before the rise or fall of BG
Start with 10% change
Signs of high basal rate (needs to be lowered)
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
Signs of low basal rate (needs to be increased)
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
rapid insulin is in the body for _` hours
rapid insulin is in the body for 3-5 hours
What is the time frame for active insulin and why do we need to tell clients about it?
Insulin still active in the body with the ability to lower glucose (previous bolus)
Helps to prevent insulin stacking
4-5 hours adults
What is the target range? What is it used for?
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
which values does the client need to put into the pump?
- insulin carb ratio
- BG before the meal
- grams of carbs
Tips for analyzing pump reports
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
Blood Glucose Targets:
FBG and pre-prandial(AC):
Post-prandial (PC):
FBG and pre-prandial(AC): 4.0-7.0 mmol/L
Post-prandial (PC): 5-8mmol/L or
5-10mmol/L
WHat are meal excursions
How much can blood glucose rise after a meal?
Average: 3mmol/L
(2.2-3.3 mmol/L)
what is the target time in range?
70%
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?
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
What do you test 1st and 2nd in terms of insulin correction
- 1st basal rate
- 2nd ISF (CF)
how long does it take for insulin to start decreasing blood sugar>
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
When to test the correction factor?
- 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
steps for testing correction factor
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
when not to use a correction dose
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
what are the signs of high ISF?
your blood sugar ends up 2 mmol/L above your target blood sugar range after 4 hrs
what are the signs of low ISF?
your blood sugar ends up 2 mmol/L below your target blood sugar range after 4 hrs
how to town that you have perfectly corrected your ISF?
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
bedtime correction factor tip
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.`
when do we need larger correction boluses?
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.
when do we need to lower our correction factors?
Weight loss and increased activity will lower your insulin needs, leading to a lower correction dose of insulin (higher
ISF).*
signs your basal rates need to be changed:
If your correction factors vary significantly throughout the day, your basal rates likely need to be changed.
Pt has a trend of going low after lunch
What are the potential causes?
ICR, ISF (too much insulin) Carb counting issues Overriding (not agreeing with pump and giving more insulin) Physical activity Alcohol consumption
when to test insulin:carb ratio?
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)
3 steps for testing your insulin:cho ratio:
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
your i:c ratio is adequate if:
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
what is the outcome of the test when i:c is to high?
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)
what is the outcome of the test when i:c is to low?
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)
reasons for unexpected BG highs/lows?
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?
what is insulin on board? when/why is it important?
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
Name and describe types of advanced bolusing
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
Calculate the amount of carbs:
Ex : 2 slices of a large all dressed pizza: 60g
Which bolus to use?
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!
what is temporary basal rate (TBR)?
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
how would you use TBR for exercise?
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
how would you use TBR for sickness?
Increase BR for 24 hrs ex. Have a fever increase 25% for 24hrs
Steps/thinking process of Reviewing Pumps
- 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!
