Newest Trends in Diabetes Management in Schools Fran Melchionne, EdD,RN,CDE BD Pediatric Diabetes Center Goryeb Childrens Hospital.

Newest Trends in Diabetes Management in Schools

Fran Melchionne, EdD,RN,CDEBD Pediatric Diabetes Center

Goryeb Children’s Hospital

Agenda

• 1. Glucose monitors and CGMS• 2. Nutrition Therapy• 3. Basal – bolus insulin therapy• 4. Injection technique• 5. Insulin pumps

Objectives

• 1. Discuss the new trends in blood glucose monitoring

• 2. State 2 advantages of CGMS• 3. Identify 2 methods to accurately count

carbohydrates• 4. Calculate a meal bolus and correction bolus

for basal-bolus insulin therapy• 5. List 2 responsibilities for an insulin pump at

school

Glucose Monitors

Trending with high and low patterns identified Touch screens Rechargeable batteries Compatible with the iPod touch/iPhone

Insulinx

• Touch screen• 3V lithium batteries• Can apply blood for up to 60 seconds• USB port to download reports• 0.3 microliters of blood• 20 – 500mg/dl results• Electronic logbook (insulin doses,exercise,etc)

Verio IQ

• Rechargeable battery• Data/battery charging port• Cannot apply more blood to test strip• 20 – 600 mg/dl• Stores 750 results• BS results must be within 3 hours of each

other to determine a pattern• 0.4 microliters of blood

iBG Star

• Rechargeable battery• Compatible with iPod touch/iPhone• Can email reports to diabetes team• Diabetes Manager App downloaded from APP

store• 0.5 microliters of blood• 20 – 600mg/dl• Memory - 300

Continuous Glucose Monitoring

• CGMS records BS levels every 5 minutes• Interstitial fluid BS• Glucose sensor is inserted under the skin• Contact sports should be avoided• Usually worn 3 – 5 days• Downloads reports • Patterns seen will result in changes in therapy

CGMS

• Two types of iPro – placed by MD or pump patient with Medtronic Paradigm pump

• Guardian – placed by patient, wears a monitor to display results

• mySentry – remotely monitors blood sugar at night – used with Medtronic Paradigm pump

• DexCom – placed by the patient, wears a monitor to display results

Nutrition Therapy

• Counting Carbohydrates• Specific gram counting• Food measurement• Reading labels• Written resources – The Calorie King – Calorie,

Fat and Carbohydrate Counter

Basal – Bolus Insulin Therapy

• Lantus – basal insulin• Novolog/Humalog/Apidra – bolus insulin used

for meal and correction boluses• Lilly HumaPen Luxura HD:can deliver ½ unit • Novo Junior Pen: does not deliver ½ unit only-

will begin ½ unit dose at 1 ½ units of insulin• NovoFlex Pen and Lantus Solostar pen are

disposable – 1 unit increments only

Basal – Bolus Insulin Therapy

• Must do an “air shot” before each injection with a pen

• BD smallest pen needle is the Nano – 32gx4mm

• Injecting with a pen: inject at a 90 degree angle – no pinching needed – count to 10 and then withdraw the needle

• Do not rub the injection site

Basal – Bolus Insulin Therapy

• Injection by syringe: prepare the skin – pinch the skin using only your thumb and index finger – inject the needle at a 90 degree angle – wait 10 seconds and withdraw the needle

• Pinching up with your entire hand may cause the injection into the muscle rather than subcutaneous tissue

• Do not squeeze the skin tightly

Basal – Bolus Insulin Therapy

• Insulin storage: • Unopened insulin is stored in refrigerator – do

not freeze• Insulin pens in use must be refrigerated if

temperature is >85 degrees• Insulin pens in use must be discarded 28 days

after opening

Basal – Bolus Insulin Therapy

• Insulin to carbohydrate ratios may be different for each meal

• Corrections cannot be done less than 3 hours after the last bolus (meal or correction)

• Targets vary for daytime and nightime • Lantus is usually given in the evening• If you treat a low BS before lunch and recheck

the BS in 15 minutes, do not correct if BS is high

Basal – Bolus Insulin Therapy

• Calculating a meal bolus:• If the insulin to carbohydrate ratio is 1unit of

insulin for every 15 grams of carb……..• The child plans to eat 45 grams of carb for

lunch = 45 divided by 15 = 3 units of insulin

Basal – Bolus Insulin Therapy

• Calculating a correction bolus:• If the correction is 1 unit of insulin for every

50 mg/dl over target:• Child has a target BS at lunch of 100, takes BS

and has 255……• Take the actual BS (255) – 100 (target) =

155mg/dl over target. Divide 155 by 50 = 3 units of insulin to correct BS of 255

Basal – Bolus Insulin Therapy

• If in the example just given it was the same child who was going to eat 45 grams of carbohydrate for lunch and BS was 255 the insulin dose prior to lunch would be:

• 3 units for the meal bolus and 3 units for the blood sugar correction = 6 units of Novolog being given.

Insulin Pumps

• Insulin pumps: continuous subcutaneous insulin infusion

• Many brands on the market • Features vary on each pump – child/family

should choose what will work for them• Delivers basal insulin 24 hours a day• Will bolus for meal and corrections of BS

Insulin Pumps

• Pumps are pager size devices that mimic normal insulin delivery

• Uses only rapid acting insulin• It is an external device• Battery operated• Delivers insulin through a small teflon catheter

Insulin Pumps

• Insulin on Board is a feature of most pumps• The amount of insulin still active at a given

time after a bolus• Advantages: decreases the risk of “stacking”

insulin • May decrease risk of intentionally running

high BS due to fear of hypoglycemia

Insulin Pumps

• The pumps are able to track the insulin that is still working in the body from the previous bolus (meal or correction) and will subtract Insulin on Board from the next correction bolus calculation to prevent hypoglycemia

Insulin Pumps

• I:C ratio, correction bolus, and target BS are entered into the pumps and when the carbs to be eaten and the BS are added … the pump will calculate the bolus to be given.

• Carbs 3.5• BG 1.7• IOB - 0.8• Total 4.4

Pumping at School

• Diabetes Medical Management Plan• specific medical orders for medication,

dosing, monitoring, carbohydrates and exercise

• treatment of hypo/hyperglycemia• child’s ability to manage the pump• diabetes equipment needed at school

Pumping at School

• Parental Responsibilities:• Provide all equipment for diabetes care• Assess carbs for school lunches• Have emergency plan if pump malfunctions• Plan for pump when child is disconnected• Able to perform infusion set changes if needed or

have alternate plan• Have a plan to insure all bolus doses are given

Pumping at School

• Pump Supply Kit• Infusion sets, meter and test strips, pump

cartridges, insulin, pump batteries, ketone strips, glucose tabs or gel, glucagon kit, insulin syringes or pens

Pumping at School

• School Responsibilities:• Follow medical plan of care • Provide for immediate treatment of low BS• Student can visit nurse as needed• Unrestricted access to fluids and restroom• Privacy to carry out diabetes care• Storage of all supplies• Notify all personnel child wears pump

Pumping at School

• School Responsibilities:• Provide training to all personnel on

symptoms and treatment of hypoglycemia• Have back up plan in the event the nurse is

not in the building

Pumping at School

• Hypoglycemia:• On the pump is treated as usual – 15 grams of

carbohydrate, wait 15 minutes and recheck BS. • If BS is > 70 mg/dl no further action• If BS is < 70 mg/dl retreat as above• Mild to moderate hypoglycemia does not

require the pump to be suspended or removed

Pumping at School

• Severe hypoglycemia: unable to treat low BS without help, potential loss of consciousness, seizure activity …… need an emergency plan

• Call 911• Give Glucagon• Notify parents/physician

Pumping at School

• Hyperglycemia without Ketones• Follow medical management plan• Check BG• Check ketones – negative• Give correction bolus for high BS• Drink water – 8 oz/30 minutes• Recheck BS in 2 hours

Pumping at School

• Hyperglycemia with Ketones• Follow medical management plan• Give correction bolus by INJECTION• Push fluids – 8 oz/30 minutes• Replace infusion set and cartridge• Recheck BS and ketones in 2 hours• Need to treat quickly to prevent DKA• Insulin injection every 2 hrs until cleared

Pumping at School

• Infusion set issues: bent, crimped, dislodged or have fallen out

• Insulin: ineffective• Site: could have infection• Tubing: air in tubing, make sure tubing is

connected at infusion set and on pump

Pumping at School

• Consider attending pump training with the student/family

• Count carbs carefully• Perform or supervise BS testing per medical

management plan• Test for ketones with BS> 300mg/dl• Hydrate for high BS• Adjust for activity with snacks or temporary

basal rate

Pumping at School

• Pumps • Animas Corporation – One Touch Ping• Medtronic Minimed – Paradigm Revel• Insulet – Omni pod (wireless)• Tandem Diabetes Care – t:slim

Thank you for your kind attention