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Pumping Pumping How Do I Start?How Do I Start?
John Walsh, P.A.John Walsh, P.A.Author: Author: Pumping Insulin, Using InsulinPumping Insulin, Using Insulin
(619) 497-0900 (619) 497-0900 www.diabetesnet.comwww.diabetesnet.com
What We’ll CoverWhat We’ll Cover
Introduction to pumpsIntroduction to pumps Advantages of pumpingAdvantages of pumping Am I a candidate?Am I a candidate? How to choose a pump and infusion setHow to choose a pump and infusion set What is needed to startWhat is needed to start Importance of dataImportance of data Site preparationSite preparation TroubleshootingTroubleshooting Formulas that helpFormulas that help Smart featuresSmart features
Where Pumps BeganWhere Pumps Began
Started ~1978 with conversion of Started ~1978 with conversion of portable chemotherapy pumps to portable chemotherapy pumps to delivery of insulindelivery of insulin
The Autosyringe AS2C and Harvard The Autosyringe AS2C and Harvard Apparatus Mill Hill Infuser were Apparatus Mill Hill Infuser were firstfirst
Single basal, no memorySingle basal, no memory 50 ml syringe on pump exterior50 ml syringe on pump exterior Required dilution of insulin Required dilution of insulin
to U-36 or U-18 to U-36 or U-181976 Biostator (top) and 1978 Autosyringe AS2C –>
The Basal-Bolus Concept The Basal-Bolus Concept
AdvantagesAdvantages
Flexibility in meal timing & sizeFlexibility in meal timing & size Eat when you want toEat when you want to Faster adjustment of Faster adjustment of
insulin for exerciseinsulin for exercise Family activities are no longer tied to Family activities are no longer tied to
one person’s needsone person’s needs Easier handling of illness, travel, or Easier handling of illness, travel, or
campingcamping
AdvantagesAdvantagesMore Consistent Insulin ActionMore Consistent Insulin Action
The same dose of NPH The same dose of NPH insulin given to the same insulin given to the same individual varies by individual varies by 25% from day to day25% from day to day
Order of variablility: Order of variablility: NPH > Lente > Lantus > NPH > Lente > Lantus > DetemirDetemir
A pump has less variable A pump has less variable insulin delivery at 3%insulin delivery at 3%
AdvantagesAdvantages
Precise doses, as small Precise doses, as small as 0.025 u, can be givenas 0.025 u, can be given
Manages the Dawn Manages the Dawn PhenomenonPhenomenon
Improves control during Improves control during growth spurts and growth spurts and adolescenceadolescence
RemindersReminders
Who Is A Who Is A Good Pump Candidate?Good Pump Candidate?
Why Choose A Pump?Why Choose A Pump?
A freer lifestyleA freer lifestyle Easier dose determinationsEasier dose determinations Improved blood sugarsImproved blood sugars Flexibility in meal timing and sizeFlexibility in meal timing and size Ability to exercise without losing controlAbility to exercise without losing control Peace of mindPeace of mind
When To Consider A PumpWhen To Consider A Pump More than 3 injections per dayMore than 3 injections per day Tired of multiple injectionsTired of multiple injections Frequent or severe hypoglycemiaFrequent or severe hypoglycemia Hypoglycemia unawarenessHypoglycemia unawareness Elevated A1cElevated A1c DKA or ER/hospital admissionDKA or ER/hospital admission Strong Dawn PhenomenonStrong Dawn Phenomenon Require small, precise dosesRequire small, precise doses Less risk of complicationsLess risk of complications
Insulin PumpInsulin Pump
ProPro Less workLess work Simplified insulin dosingSimplified insulin dosing Precise deliveryPrecise delivery Greater impact in those Greater impact in those
with highest starting A1cwith highest starting A1c Slightly less insulin use Slightly less insulin use
per dayper day
ConCon More DKAMore DKA More severe More severe
hypoglycemiahypoglycemia A1c levels and A1c levels and
frequency of DKA & frequency of DKA & hypoglycemia are hypoglycemia are similar to ICTsimilar to ICT
What It Takes To SucceedWhat It Takes To Succeed
A personal desire for better control A personal desire for better control Willing to adjust insulin doses to carb Willing to adjust insulin doses to carb
count, test results, and activitycount, test results, and activity Willing to monitor at least 4 times a dayWilling to monitor at least 4 times a day Willing to keep an accurate record of Willing to keep an accurate record of
BGs, boluses, and carb countsBGs, boluses, and carb counts Committed to solve problems and adapt Committed to solve problems and adapt
lifestyle as neededlifestyle as needed
Success For Kids On PumpsSuccess For Kids On Pumps
Supervision is required: kids BEGIN to Supervision is required: kids BEGIN to develop self care skills at about age 10develop self care skills at about age 10
Family support is essential: an adult who can Family support is essential: an adult who can go to school, etc.go to school, etc.
Communication with a health care team that is Communication with a health care team that is committed to pumpscommitted to pumps
Adequate insurance and financial resourcesAdequate insurance and financial resources Assistance and support from teachers, Assistance and support from teachers,
friends, babysitters, grandparents, siblingsfriends, babysitters, grandparents, siblings
Features For Infants & ToddlersFeatures For Infants & Toddlers
Little ones are ideal pump candidates if the Little ones are ideal pump candidates if the parents areparents are
Delay or split boluses for fussy eaters Delay or split boluses for fussy eaters Small, user-friendly pumps offer precise Small, user-friendly pumps offer precise
dosing (0.05, 0.025, or 0.01 unit increments)dosing (0.05, 0.025, or 0.01 unit increments) Lock outLock out Worn between shoulder bladesWorn between shoulder blades If a toddler likes to remove the If a toddler likes to remove the
infusion set, let them know what infusion set, let them know what comes out must go right back incomes out must go right back in
Help For Kids & TeensHelp For Kids & Teens
Growth spurtsGrowth spurts Dawn PhenomenonDawn Phenomenon Easy coverage of snacksEasy coverage of snacks TDD and bolus history can be checked TDD and bolus history can be checked
to ensure consistent dosingto ensure consistent dosing Faster adjustment of basals and boluses Faster adjustment of basals and boluses
for changes in activity, etcfor changes in activity, etc
Special Teen ConcernsSpecial Teen Concerns
DatingDating Wearing, sharingWearing, sharing AlcoholAlcohol Eating disordersEating disorders Fast foodsFast foods FabricationFabrication Sleeping-inSleeping-in
Personal EffortPersonal Effort
Those who expect a pump Those who expect a pump to manage their diabetes to manage their diabetes
for them will fail to for them will fail to optimize their own optimize their own
therapy.therapy.
Learn how to adjust your basals and boluses for an excellent A1c!
First Steps Toward A PumpFirst Steps Toward A Pump
Keep detailed recordsKeep detailed records Consider your (and your child’s) motivationConsider your (and your child’s) motivation
Peer group, acceptance issues, family supportPeer group, acceptance issues, family support
Look at available pumpsLook at available pumps Which pump(s) does your insurance cover?Which pump(s) does your insurance cover? Talk with your doctor about a prescriptionTalk with your doctor about a prescription Visit a dietician to learn carb countingVisit a dietician to learn carb counting
What To LearnWhat To Learn
How your pump worksHow your pump works How to count carbs How to count carbs How to interpret BG results How to interpret BG results
and see BG patterns and see BG patterns When to increase and When to increase and
decrease basals and boluses decrease basals and boluses How to adjust for high GI foods, extra How to adjust for high GI foods, extra
activityactivity
How ToHow ToChoose A PumpChoose A Pump
Pump CompaniesPump Companies
Who sell or plan to sell Who sell or plan to sell pumps in the US:pumps in the US:
Animas R1200 Animas R1200 Dana Diabecare IIIDana Diabecare III Deltec CozmoDeltec Cozmo Medtronic Paradigm Medtronic Paradigm Nipro AmigoNipro Amigo Roche/DisetronicRoche/Disetronic
Visit www.diabetesnet.com/diabetes_technology/
Things To ConsiderThings To Consider
Look, feel, colorLook, feel, color Features: reminders, child block, waterproofingFeatures: reminders, child block, waterproofing Size of basal and bolus incrementsSize of basal and bolus increments Infusion set choicesInfusion set choices Safety and reliabilitySafety and reliability Customer supportCustomer support History History Ease of data analysisEase of data analysis Add-ons: meters, covers, casesAdd-ons: meters, covers, cases
Today’s Smart PumpsToday’s Smart Pumps
Easy dose calculations with Carb Factor Easy dose calculations with Carb Factor and Correction Factorand Correction Factor
Precise insulin dosing (0.05 units or better) Precise insulin dosing (0.05 units or better) to allow basal rates to be set up for Dawn to allow basal rates to be set up for Dawn Phenomenon, etc.Phenomenon, etc.
Tracks BOB to avoid insulin stackingTracks BOB to avoid insulin stacking RemindersReminders
Today’s PumpsToday’s Pumps
When control is poor or varies greatly on When control is poor or varies greatly on one of today’s pumps, the pump settings one of today’s pumps, the pump settings are incorrect.are incorrect.
Test and reset basal rates, carb and Test and reset basal rates, carb and correction factors until you have good correction factors until you have good control.control.
Garbage in…..Garbage in…..
How To Choose How To Choose An Infusion SetAn Infusion Set
Infusion SetsInfusion Sets Straight-In Teflon: Cleo, Inset, Straight-In Teflon: Cleo, Inset, Ultraflex, Quik-SetUltraflex, Quik-Set
Easier to insert, variety of depths (6, 8, 9 mm)Easier to insert, variety of depths (6, 8, 9 mm) Angled Teflon Angled Teflon (Comfort, Tender, Easy, Silhouette):(Comfort, Tender, Easy, Silhouette):
Fewer failuresFewer failures Insertion site is visible Insertion site is visible Longer is more secureLonger is more secure Adjust angle to reach fatAdjust angle to reach fat
Metal needles Metal needles (Rapid-D or bent needle)(Rapid-D or bent needle) As comfortable and often more reliableAs comfortable and often more reliable Very short, multi-needle infusion sets expected soonVery short, multi-needle infusion sets expected soon
Infusion Sets And InsertersInfusion Sets And Inserters
Smith’s Medical CleoSmith’s Medical Cleo
Medtronic Sil-serterMedtronic Sil-serter
Disetronic Rapid-DDisetronic Rapid-D
Animas InsetAnimas InsetQuik-serterQuik-serter
Site SuppliesSite Supplies Emla cream (Rx, 30 min wait) or ice cubeEmla cream (Rx, 30 min wait) or ice cube Set inserter: Cleo and Inset are self-contained, Set inserter: Cleo and Inset are self-contained,
ezSerter, Quick-Serter, Sil-Serter, Sof-SerterezSerter, Quick-Serter, Sil-Serter, Sof-Serter Adhesive: IV-3000, Hypafix, TegadermAdhesive: IV-3000, Hypafix, Tegaderm Stickies: Skin Tac-H, Skin PrepStickies: Skin Tac-H, Skin Prep Tape: Micropore, Durapore, Tape: Micropore, Durapore,
Band-Aid Blister Relief (wicking)Band-Aid Blister Relief (wicking) Sweating aid: Mastisol Spray Sweating aid: Mastisol Spray
(Detachol for removal), Skin Tac, (Detachol for removal), Skin Tac, Tincture of Benzoin, Skin PrepTincture of Benzoin, Skin Prep
Adhesive removal: Uni-Solve, AllkareAdhesive removal: Uni-Solve, Allkare
School SuppliesSchool Supplies Meter, lancets, test stripsMeter, lancets, test strips Glucagon, glucose tablets, or Glucagon, glucose tablets, or
crackers for lows crackers for lows Spare insulin, syringes or insulin pen Spare insulin, syringes or insulin pen Spare infusion set and pump batteriesSpare infusion set and pump batteries Ketostix or Precision Xtra to test for ketonesKetostix or Precision Xtra to test for ketones Information card with insulin-to-carb ratio, Information card with insulin-to-carb ratio,
formula for correctionsformula for corrections Telephone numbers of parents, health care Telephone numbers of parents, health care
providers, and pump manufacturer's help lineproviders, and pump manufacturer's help line
How To StartHow To Start
Starting On A PumpStarting On A Pump
Everyone is nervousEveryone is nervous Read, read, readRead, read, read
• Pumping Insulin, Kids Insulin Pumps And You Pumping Insulin, Kids Insulin Pumps And You (Animas), (Animas), www.childrenwithdiabetes.comwww.childrenwithdiabetes.com, , www.pumps4kids.cawww.pumps4kids.ca, etc, etc, etc, etc
Do lots of recording before and after startDo lots of recording before and after start Start to play with pump as soon as it arrivesStart to play with pump as soon as it arrives Saline practice helpsSaline practice helps Get telephone contacts: MD, CDE, pump Get telephone contacts: MD, CDE, pump
company, pump rep, other parentscompany, pump rep, other parents
Helpful Attitudes And HabitsHelpful Attitudes And Habits
Be blatant about your diabetesBe blatant about your diabetes A pump is a tool, not a cureA pump is a tool, not a cure Take a bolus for every biteTake a bolus for every bite Change site as directedChange site as directed Look for a solution for every problemLook for a solution for every problem Write down a reason for every low and highWrite down a reason for every low and high Test oftenTest often
John’s Pump RulesJohn’s Pump Rules
• Total Daily Dose = weight in lbs / 4Total Daily Dose = weight in lbs / 4
• Basal Dose = 50% to 60% of TDDBasal Dose = 50% to 60% of TDD
• Carb Factor = 500 / TDDCarb Factor = 500 / TDD
• Correction Factor = 2000 / TDDCorrection Factor = 2000 / TDD
• BG target = 90 to 120 mg/dlBG target = 90 to 120 mg/dl
• Basal target = +/- 30 mg/dlBasal target = +/- 30 mg/dl
• BOB = 20% per hourBOB = 20% per hour
• Correction boluses = < 8% of TDDCorrection boluses = < 8% of TDD
J Walsh and R Roberts: Pumping Insulin, 2005
Starting Insulin DosesStarting Insulin Doses
J Walsh and R Roberts: Pumping Insulin, 2005
Carb Counting And Recording Carb Counting And Recording As Ways To Lower The A1cAs Ways To Lower The A1c
Steps For A Better A1cSteps For A Better A1c
Carb counting – 0.6%Carb counting – 0.6% Givivg boluses based on an accurate carb count Givivg boluses based on an accurate carb count
– 0.3%– 0.3% Recording test results, carb intake, insulin Recording test results, carb intake, insulin
doses, & activity – 0.5%doses, & activity – 0.5%
Monitoring often – 0.5-2.0% Monitoring often – 0.5-2.0% Bolusing often – 0.5-2.0%Bolusing often – 0.5-2.0% Contacting your doctor or adjusting your own Contacting your doctor or adjusting your own
doses when you encounter unwanted BGsdoses when you encounter unwanted BGs
Carb CountingCarb Counting
Allows precise matching of carbs with Allows precise matching of carbs with bolusesboluses
Glycemic index, saturated fat, and high Glycemic index, saturated fat, and high protein all play a role, but grams of carb is protein all play a role, but grams of carb is what controls the blood sugar after a mealwhat controls the blood sugar after a meal
Easy!Easy!
Where Carbs Come FromWhere Carbs Come From
fruit/fruit juicefruit/fruit juice breads/bagelsbreads/bagels cerealscereals crackerscrackers grainsgrains muffinsmuffins ricerice potatoes/yamspotatoes/yams vegetablesvegetables
1 gram of carb
raises the BG
4 to 7 points!
dessert/cookies/cake/piedessert/cookies/cake/pie ice cream/frozen dessertice cream/frozen dessert sweetened beveragessweetened beverages milk/yogurt (not cheese)milk/yogurt (not cheese) beer/winebeer/wine honey/syrup/molasseshoney/syrup/molasses jams/jellys/preservesjams/jellys/preserves -ose foods like sucrose -ose foods like sucrose
(table sugar)(table sugar)
How To Count CarbsHow To Count Carbs
Food labelsFood labels Check portion sizeCheck portion size
BooksBooks Dr’s Pocket Guide, Health ChequesDr’s Pocket Guide, Health Cheques
A gram scale plus carb factorsA gram scale plus carb factors Carb factors are available in Pumping Carb factors are available in Pumping
Insulin and are built into scales like the Insulin and are built into scales like the Salter computer gram scaleSalter computer gram scale
Blood Sugar Testing – 1921Blood Sugar Testing – 1921
Blood Sugar Testing – 2004Blood Sugar Testing – 2004
Blood Sugar Testing – 2004Blood Sugar Testing – 2004
“I just don't write down (log) anything. I hate to take the time to do it. I'd rather have a machine talk for me. I think it revolves around partial general laziness, as well as the constant reminder of being different from everyone else. I know other diabetics who won't even test when they're out with friends. They hate ….”
The Artiste 6/28/04
Smart Charts
Needed to solve Needed to solve problemsproblems
Basis for better Basis for better diabetes health carediabetes health care
~0.5% drop in A1c~0.5% drop in A1cBlood sugar, insulin, food, activity, stress
Charting Improves ControlCharting Improves Control
Better Charts, Better A1cBetter Charts, Better A1c
ChartsCharts My Other CheckBookMy Other CheckBook
SoftwareSoftware Meter companiesMeter companies Internet: myhealthchannel.comInternet: myhealthchannel.com Pump Control SoftwarePump Control Software
Meters, PDAs & PumpsMeters, PDAs & Pumps Pump: Deltec, Disetronic, Animas, MedtronicPump: Deltec, Disetronic, Animas, Medtronic Meter: BD, Therasense, Lifescan, BoerhingerMeter: BD, Therasense, Lifescan, Boerhinger
Analyze Carb BolusesAnalyze Carb Boluses
1. Count carbs
2. Give carb bolus
3. Eat
4. Record BGs
5. Analyze BGs
6. Balance better next time
Match Your Carbs With BolusesMatch Your Carbs With Boluses
Accounts for Accounts for HALFHALF the day’s control! the day’s control! Keeps blood sugar normal after mealsKeeps blood sugar normal after meals Requires accurate carb counting and an Requires accurate carb counting and an
accurate carb factoraccurate carb factor 500 Rule provides a close estimate of 500 Rule provides a close estimate of
carb factor if the TDD is accuratecarb factor if the TDD is accurate
500 Rule To Find Carb Factor500 Rule To Find Carb Factor
Gives grams of carb covered by one unit of Gives grams of carb covered by one unit of Humalog or NovologHumalog or Novolog
500 / TDD = 500 / TDD = grams of carb per unit of insulingrams of carb per unit of insulin Example:Example:
Person’s TDD = 50 unitsPerson’s TDD = 50 units 500/50 = 500/50 = 10 grams of carb10 grams of carb covered by covered by
1 unit of Humalog or Novolog 1 unit of Humalog or Novolog Postmeal readings stay normal!Postmeal readings stay normal!
2000 Rule To Find Correction Factor 2000 Rule To Find Correction Factor
Gives how far your blood glucose is likely to fall per Gives how far your blood glucose is likely to fall per unit of insulin over 5 hoursunit of insulin over 5 hours
2000 / TDD = 2000 / TDD = # mg/dl your BG will fall per unit# mg/dl your BG will fall per unit
Example:Example: Person’s TDD = 25 unitsPerson’s TDD = 25 units 2000/25 = an 2000/25 = an 80 mg/dl drop80 mg/dl drop per unit of H or Nov per unit of H or Nov
Adapted from 1500 Rule by Dr. Paul Davidson, Atlanta, GAAdapted from 1500 Rule by Dr. Paul Davidson, Atlanta, GA
2000 Rule2000 RuleTotal Daily Dose Point drop per unit
20 units 90 pts 25 units 72 pts 30 units 60 pts 35 units 51 pts 40 units 45 pts 50 units 36 pts 60 units 30 pts 75 units 24 pts
1600, 1800, 2000, or 2200 may be divided by TDD to get point drop per unit
1800 provides a good average --- 1600 Rule is more aggressive and gives more insulin, while a 2000 or 2200 Rule gives less insulin
New DevicesNew Devices
Data storage and downloadData storage and download Easy recording of BGs, Easy recording of BGs,
insulin, carbs, activityinsulin, carbs, activity Automatic carb countingAutomatic carb counting Pattern recognitionPattern recognition Insulin dose guidanceInsulin dose guidance Data analysis to improve control Data analysis to improve control Feedback that encourages useFeedback that encourages use
Pump — Meter CombosPump — Meter Combos
CozMonitor from Deltec CozMonitor from Deltec and Therasenseand Therasense
Disetronic and Roche Disetronic and Roche Medtronic 512 and BD Medtronic 512 and BD
Paradigm LinkParadigm Link Animas and LifescanAnimas and Lifescan Dana Diabecare III and Dana Diabecare III and
Dana meterDana meter
TroubleshootingTroubleshooting
Most Pump Problems Occur InMost Pump Problems Occur In
First weekFirst week First monthFirst month First 6 monthsFirst 6 months
Problems are most likely when unexpected or inconvenient
Occasional Pump ProblemsOccasional Pump Problems
Setup tipsSetup tips LeaksLeaks
O-ringsO-rings HubHub LineLine
ClogsClogs Site infections Site infections
and abscessesand abscesses
AllergiesAllergies BleedingBleeding
onto skinonto skin inside needleinside needle under skinunder skin
Pump bumpsPump bumps HypertrophyHypertrophy DKADKA
Some frustration at times is normal!
Set And Site IssuesSet And Site Issues
Dislodged infusion setDislodged infusion set TunnellingTunnelling
Rapid-D and slanted Teflon sets Rapid-D and slanted Teflon sets work better for mobile kidswork better for mobile kids
Metal may be better than teflonMetal may be better than teflon InfectionInfection HematomaHematoma
Site PreparationSite Preparation
Prevents pump bumps, infection, and Prevents pump bumps, infection, and abscessabscess
StepsSteps Wash the handsWash the hands Sterilize the skin – IV PrepSterilize the skin – IV Prep Use bio-occlusive adhesive – IV 3000Use bio-occlusive adhesive – IV 3000 Insert the setInsert the set Use safety tapeUse safety tape
Will Your Pump Alarm?Will Your Pump Alarm?
Low batteryLow battery
Mechanical problemMechanical problem
Empty reservoirEmpty reservoir
ClogClog
Forgotten bolusForgotten bolus
LeakLeak
BleedingBleeding
Bad programmingBad programming
Dislodged infusion setDislodged infusion set
YesYesYesYesYesNoNoNoNo
How To Check Mechanical ProblemsHow To Check Mechanical Problems
Check from Check from
skin to pump:skin to pump:
Skin and siteInfusion setConnectionLineHubReservoirPump
High BG ChecklistHigh BG Checklist
See a leak or smell insulin?See a leak or smell insulin? Infusion set in place? Infusion set in place? Was infusion set primed?Was infusion set primed? Are connections at hub and O-rings tight? Are connections at hub and O-rings tight? Bubbles in the tubing? One inch = a half unitBubbles in the tubing? One inch = a half unit Clog in line? Clog in line? Alarms? Errors?Alarms? Errors?
If no cause is found, replace everything!
Test for all BGs over 300Test for all BGs over 300 Always test when nauseousAlways test when nauseous Test urine with KetodiastixTest urine with Ketodiastix Test blood with Precision Xtra meterTest blood with Precision Xtra meter
Earlier detectionEarlier detection No need to collect urineNo need to collect urine Keep currently dated strips availableKeep currently dated strips available
Go to ER at 1Go to ER at 1stst sign of vomiting! sign of vomiting!
Check Ketones EarlyCheck Ketones Early
More Insulin For More Insulin For Unexplained High BGsUnexplained High BGs
When a blood glucose test is unexpectedly When a blood glucose test is unexpectedly high, the correction bolus needed to lower high, the correction bolus needed to lower this will be much higher than normally this will be much higher than normally requiredrequired Loss of basal insulin delivery for several hoursLoss of basal insulin delivery for several hours Insulin resistance from length of Insulin resistance from length of
hyperglycemiahyperglycemia Insulin resistance from presence of ketonesInsulin resistance from presence of ketones
ConclusionConclusion A pump offers the latest A pump offers the latest
technology for precise insulin technology for precise insulin deliverydelivery
Requires commitment and Requires commitment and responsibilityresponsibility
Benefits include more flexibility, Benefits include more flexibility, less hypoglycemia, improved less hypoglycemia, improved control, and a longer, healthier control, and a longer, healthier lifespanlifespan
Make the commitment and start Make the commitment and start pumping!pumping!
QuestionsQuestions??????