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Introduction to Insulin Pump Therapy
What is an insulin pump and how does it work?
• Aninsulinpumpisasmallelectronicdevicewhichprovidesacontinuousinfusionofveryfastactinginsulin(NovorapidorHumalog)intothesubcutaneoustissue(undertheskin).Itisdesignedtodeliverinsulininawaymoresimilartothepancreasofapersonwithoutdiabetes,thaninsulininjections.
• Thepumpisprogrammableandthesettingscanbechangedifrequiredbyactivatingtheon-screenmenus(patients/parentsaretrainedhowtochangethesettings).
• Insulinisdeliveredthroughaninfusionsetfromthepump,andashortplasticcannulawhichischangedevery2-3daysusinganeedleinsertionset(seethepicturebelow).
• AllpatientsrequireacontinuousinfusionofNovorapidorHumalogwhichactasbasal(orbackground)insulinandtheremaybeseveraldifferentbasalratesettingsoverthecourseoftheday.
• Insulinbolusesarerequired,inadditiontothebasalinsulin,whencarbohydrate-containingfoods/drinksareconsumed.Thebolusisgiventhroughthepump,andthesettingsfortheamountofinsulinrequiredforcarbohydratearepre-programmedintothepump.
• Aninsulinbolusisalsorequiredwhenthebloodglucosereadingishighandtheamountofinsulinrequired(correctionfactor)isprogrammedintothepump.
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Who is eligible for insulin pump therapy?
a) Foradults and children 12 years and olderthereasonsforrequiringapumpare:
• IfattemptstoreachtargethaemoglobinA1c(HbA1c)levelswithmultipledailyinjectionsresultinthepersonhaving‘disablinghypoglycaemia’.
• IfHbA1clevelshaveremainedhigh,above70mmol/mol,withmultipledailyinjectionsdespitethepersonand/ortheircarercarefullytryingtomanagetheirdiabetes.
b) Forchildren aged less than 12 years,pumptherapyisrecommendedasapossibletreatmentforallchildren.TheNICEguidelinesadvisethatchildrenwhouseinsulinpumptherapyshouldhaveatrialofmultipledailyinjectionswhentheyarebetweentheageof12and18years.
What does starting on insulin pump therapy involve?
Startinganinsulinpumprequiresabigcommitmentandtakesmoretimeandeffortthanmanagingdiabeteswithinjections.Ifyouputinthetimeandeffortitcanallowflexibilityandgoodbloodglucosecontrol.Itisnotaneasyoption!
The commitment includes:
• Frequentbloodglucosetesting(minimumof8testsperday).
• Keepingadailywrittendiaryofbloodglucoseresultsandevents.
• Veryaccuratecarbohydratecounting.
• Regularcommunicationwiththediabetesteamandclinicattendance.
IftheHbA1cbeforestartingpumptherapyisabove60mmol/mol,adropby7mmol/molshouldbeexpected.Thisneedstobemaintained.
What happens if I become/my child becomes unwell when on insulin pump therapy?
Itisvitaltounderstandtheincreasedriskofdevelopingdiabeticketoacidosiswhenusinginsulinpumptherapy,andbeabletomanagesickdaysappropriately.Theusual24houradvicelinewillnotbeabletoofferadviceforadjustmentofpumpsettings.Itmaybenecessaryinthesecircumstancestoreturntoinsulininjections.Thismaybethecaseifadmissiontohospitalisrequiredduetoillnesswithhighbloodglucosereadingsandhighbloodketones.
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The insulin given through the pump is very fast acting insulin, therefore progression to ketoacidosis can occur within four hours if you/your child are not receiving insulin from the pump.
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What other equipment is required?
Acomputerisrequiredtodownloadpumpdata,toreviewbloodglucosereadingsandpumpsettings.Thesedownloadsareemailedtothediabetesteambeforeclinics.
What happens if the insulin pump is damaged?
Youshouldinsurethepumponyourhomeinsurancepolicy.Inaddition,thereisacompanywarranty.
How long would it take to start insulin pump therapy?
Theclinicalneedandassessmentofsuitabilitywillbethedecidingfactorsforprogressingthroughtheprepumpprocess.Ifitisagreedthatapatientneedspumptherapythenanassessmentofpriorityisrequired.Anurgentrequirement,e.g.diabetesinababy,willtakepriority.
Thereisawaitinglistforinsulinpumptherapy.Peoplearestartedonpumpsingroupsoftwoorthree,dependingontheirage.Thediabetesteamcangiveyouguidanceastohowlongyouwouldbeexpectedtowaitforaninsulinpump.
What happens if insulin pump therapy is not working well?
ThepumpremainsthepropertyofNHSLothian.Youwillbeaskedtosignanagreementtoreturnthepumpifitisnotbeingusedappropriately.
Somepeopleexperiencedifficultieswithinsulinpumptherapy.Thediabetesteamwillsupportyouwithanydifficulties,howeverifyou/yourchilddecidethatyouwouldprefernottobeoninsulinpumptherapy,youcanconvertbacktoinsulininjections.ThepumpwouldthenbetakenbackbyNHSLothian.
What do I do if I/my child would like to try insulin pump therapy?
Ifyouareinterestedininsulinpumptherapypleasediscusswiththediabetesteamatyournextclinicvisit.
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PAGE 4INSULIN PUMPSINSULIN PUMPS
Pre Insulin Pump Process
Ifyouareinterestedininsulinpumptherapy,thisistheexpectedprocessfollowingyourinitialenquiry.
Family enquiry about insulin pump therapyDiscussionatclinic,andwritteninformationsenttofamily.
Cliniclettersent,includingdocumentationthatpumpinformationhasbeensent.
Family wish to proceedInitiationofpumpprocessatnextclinicvisit:
Familyneedtoanswerthreequestionsaboutinsulinpumptherapycorrectly.Pumpreferralsheetfilledinbydoctoratclinic.
Patients referred for pump therapy discussed at diabetes team meeting, last Monday of month
Patientaddedtopumpwaitinglist.Lettersenttofamilyconfirmingpatientonpumpwaitinglist.
Family invited to pump show
Referred for pre-pump psychology assessment
4 months before expected pump startPumpstartgroupsagreedbydiabetesteam.
Lettersenttofamilywithexpectedpumpstartdate.
4 months before expected pump startFamilymeetwithdietitian.
Dietitianassessmentandsignoff-acuratecarbohydratecounting.
3 months before expected pump start dateFamilymeetwithDNS.
DNSassessmentandsignoff-readinessforpumptherapyandexpectations.
2 months before expected pump start dateDatesandpaperworkforpumpstartsenttofamily
(seepumptrainingprogrammeprocess).
1 month before expected pump start datePumpdeliveredtofamilyhome.
Pumpagreementandpre-pumppreparationsheetsenttofamily.
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Insulin Pump Start Process
Week 1
Childrenundersevenyearsofage
Groupsoftwofamilies
Visit1–ParentsattendRHSCforinsulinpumpeducation
Visit2–ParentsandchildrenattendRHSCforinsulinpump‘saline’start
Childrenoversevenyearsofage
Groupsofthreefamilies
Visit1–ParentsandchildrenattendRHSCforinsulinpumpeducationandinsulinpump‘saline’start
Week 2
Groupsoffamiliesattendforreviewofprogressfollowinginsulinpumpsalinestart,and‘golive’insulinpumpinsulinstart
Telephoneoncalladviceanddailyfollowupphonecallsfromdiabetesteam
Week 3
FamilyphoneDNSonWednesdaytoreviewBGreadingsandprogress
Week 4
Beginningofweek-Familysendininsulinpumpdownloadsforprevioustwoweeks
Downloadstosend: Devicesettings
Quickviewsummary
Logbookdiary
Modaldaybyhour
Endofweek–FamiliesattendRHSCforgroupreviewandeducationsessionwithdiabetesteam
Week 8-10
ReviewappointmentinWednesdayafternoondiabetesreviewclinic
PumpdownloadsforprevioustwoweekstobesenttodiabetesteamonMondaybeforeclinic
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Top Tips When Starting on an Insulin Pump
Usethissectionasaguidefollowingyour/yourchild’spumpstartdate.Whenmoreexperiencedwithinsulinpumptherapy,youwillfindmoredetailedinformationinthe‘Day-to-DayInsulinPumpManagement’section.
1. When should BG readings be checked?
AimtocheckaBGreadingbeforeand2hoursaftercarbohydrateintake.Initially,alsocheckBGapproximately3hourlyovernighte.g.midnight,3amand6am.
RemembertorepeataBGreading1hourafteranysignificantpumpevente.g.setchange,treatingahypo,pencorrectionforhighbloodglucose/ketones.
BGreadingsshouldberecordedonthedailyrecordsheets,alongwithCHOintakeandinsulindosesforthefirstweekafterthepumpstart.Followingthis,youcanchangetotheMedtronicdailydiary,howeveryoumayprefertocontinueusingthedailyrecordsheetsforlonger.
2. What should I/my child eat and drink following the pump start?
Aimtoeatthreemealsperday.Asmallsnack,coveredwithabolus,betweenmealsisoptional.Ideallythereshouldbeatleast2hoursbetweenmealsandsnacksinitially,toassesstheinsulintocarbohydrateratios.
3. How does the pump calculate a bolus insulin dose?
Thepumpisprogrammedwithyourinsulintocarbohydrateratios,correctionfactor,andbloodglucosetargets.Thepumpcanthereforeworkouthowmuchbolusinsulinisrequired.Thereisalsoasafetyfeaturewhichpreventsanoverbolusofinsulin.Allthesefeaturesarecombinedinthepumpsoftware.Thebolusfunctioniscalledthe‘boluswizard’.
4. When should an insulin bolus be given?
Boluswizardshouldbeusedtocalculateanappropriateinsulinbolusforallcarbohydrateintake.Aimtogiveaninsulinbolus10minutesbeforemeals(upto20minutesbeforebreakfast),forthecarbohydratewhichyouknowyou/yourchildwilleat.IfmoreCHOthanexpectedisconsumed,bolusfortheadditionalCHOasitistaken.
Useboluswizardtoensurecorrectionbolusesaregivenwhenappropriate,everytimetheBGis>7mmol/L,throughoutthedayandnight.Ifthereisactiveinsulin,boluswizardwilltakethisintoaccount,andcalculatetheamountofcorrectionrequired.
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5. How do I manage hypoglycaemia on a pump?
Giveshortactingglucoseasyouwouldhavedonepreviously.BGshouldbere-checkedafter10-15minutes.
IftherepeatBGis<4mmol/L,repeatthehypomanagement.
Thereisnoneedtogiveextra‘free’carbohydratewhentheBGhasrisento>4mmol/Lwhileusinganinsulinpump,asalltheinsulininthepumpisveryfastactinginsulin.
AnyadditionalCHOconsumedshouldbecoveredwithinsulinasindicatedbytheboluswizard.
Iftherearetwoseparateepisodesofhypoglycaemiawithinonehour,setatemporarybasalrateof50%(see‘Managementofhypoglycaemiaonaninsulinpump’flowchartonpage15).
RepeattheBGonehourafterthehypohasbeensuccessfullytreated,orsoonerifyouareconcerned.
IftheBGis>7mmol/Lwithintwohoursoftreatingahypo,youshouldnotgiveacorrectionbolus.IfeatingadditionalCHO,enteraBGof7mmol/Ltothepump,itwillthenonlybolusforthecarbohydrate.
IftheBGis>7mmol/Lmorethantwohoursaftertreatingahypo,useboluswizardtocalculateacorrectionbolus.
6. How do I manage high blood glucose readings >14mmol/L on a pump?
Theinsulingiventhroughtheinsulinpumpisveryfastactinginsulin,thereforeketonescandeveloprapidlyifthereisanyinterruptiontoinsulindelivery.
ImmediateactionisrequirediftheBGis>14mmol/L,initiallybycheckingforketones.Seethe‘ManagementofHyperglycaemia’and‘InsulinPumpTherapyDuringIntercurrentIllness’flowcharts.
Hyperglycaemiacanoccurformanyreasons.Itisimportanttocheck:
• Thereisnoleakagefromtheinfusionsetorcannula.
• Thecannulahasnotbecomedislodged.
• Thecannulaandinsertionsethasnotbeenwornformorethan72hours.
• Therearenolargeairbubblesintheinfusionset.
• Thecorrectbasalrateisset.
• Thecorrectbolusdosehasbeengiven(checkbolushistory).
• Thecannulaisnotinsertedintoalumpysite.
• Thepumpisworkingproperly(doa‘selftest’).
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7. Can the insulin pump be disconnected?
Theinsulinpumpcanbedisconnectedforshortperiods,e.g.showering,dressing,datadownload.Aimtokeepthistimeasshortaspossible,notlongerthanonehour.
Smallchildrenareoftenonultralowbasalrates,whichwillbedeliveredatsettimes.
e.g. 0.025units/hour-thiswillbedeliveredasabolusoneachhour(00:00,01:00,02:00etc).
0.05units/hour-thiswillbedeliveredasabolusof0.025unitsoneachhalfhour(00:00,00:30,01:00,01:30etc).
Thereforedonotdisconnectthepumpatthesetimes.
8. What if I think there is a problem with the pump?
TreatahighBGfollowingthe‘Hyperglycaemia’flowchart(page16).
Doaselftest.Iftheproblempersists,contacttheMedtronichelpline.
Ifthepumphasfailed,youwillneedtoreverttoinsulininjections,usingyourprepumpstartinsulindoses.
9. How do I manage activity following the pump start?
Theexpectationisthatthepumpstartweekwillinitiallybea‘quiet’week.Wewillencourageagradualincreaseinactivitytonormallevelsafterthefirstfewdays.
Whenthereisplannedexercise,setatemporarybasalrate(70%oftheusualbasal)starting60minutesbeforeandcontinuinguntil60minutesaftertheplannedexercise.Atemporarybasalratecanbecancelledatanytime.
Ifthereisunplannedexercise,additionalcarbohydrateisrequired,justasyouhavedonepreviously,topreventahypo.Atemporarybasalratemaystillberequiredifexerciseismoderateandlastslongerthan30minutes.Theeffectofalowerbasalratetakesuptoanhourtohaveanybenefit,whichiswhytheextraCHOisneededatstartofexercise.
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Day-to-Day Insulin Pump Management
1. What are the blood glucose (BG) targets while on pump therapy?
Thebloodglucosetargetshouldbesetat5-7mmol/Lonthepump,toallowboluswizardtocorrecttothistarget.
Generally,BGreadingsbeforemealsandbeforebedof4-8mmol/Lareacceptable,andwouldnotpromptachangeinbasalinsulinrates.
Twohoursafterameal,aBGof<9mmol/Lisacceptable.
IftheBG2hoursafteramealisabovetarget,increasetheinsulintocarbohydrateratio(ICR)byapproximately10-20%.Youwillthereforemakingminoradjustmentsregularly.
Forexample,ifyouwereusing1unit:13grams,changeto1unit:11grams.
2. When should insulin boluses to cover carbohydrate be given?
Givethebolustocovercarbohydrate10minutesbeforethemeal(orupto20minutesbeforebreakfast),forwhatyouknowwillbeeaten.Thiswillresultinoptimalbloodglucosecontrol.
BolusforanyadditionalCHOassoonasitiseaten(withoutenteringarepeatBG).
Rememberthatinsulinisabsorbedmorequicklybytheeffectsofexerciseandheat.Donotwait10-20minutesbeforeeatingifimmediatelyafterahypo.
3. How do I know if the basal rates need to be adjusted?
Wesuggestthatyouperformabasalratereviewevery4-6weeks.Reviewonlyonetimeintervalperday.
Ifbloodglucoseis4-8mmol/Lbeforeamealoratbedtime,omitthenextmealandsnack(orgiveaCHOfreemeal/snack)andcheckBGeverytwohours.Foranovernightbasalreview,havealightlowfatmealat5pm,thennothingafterwards.
TheBGshouldstaywithin2mmol/LoftheoriginalBGreading.
Carryoutthebasalratereviewprocessfrom:
a) Beforebreakfasttobeforelunch
b) Beforelunchtobeforetea
c) Beforeteatoafterbedtime
d) Overnight
Ifthebloodglucoselevelsriseorfallbymorethan2mmol/L,makeadjustmentstothebasalratestwohoursbeforetheriseorfall.
Whileperformingabasalratereview,donotgiveacorrectionbolusunlesstheBGis>14mmol/L,sothatyoucanseethebasalpatternclearly.
Once stable, checking BG before and 2 hours after meals as an 8 point profile is the ideal daily profile.
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Wesuggestthefollowingchanges,basedontotaldailydoseofinsulin(TDD):
TDD Adjustment
TDDlessthan10units makeadjustmentsby0.025unitsperhour
TDD10-20unitsperday makeadjustmentsby0.05unitsperhour
TDD20-40unitsperday makeadjustmentsby0.1unitsperhour
TDDgreaterthan40unitsperday makeadjustmentsby0.2unitsperhour
Example
TDDofinsulinonpump:15.6unitsperday
Overnightbasalreview
1800–Lightmeal,30gCHOeaten,bolusgivenviaboluswizard.
Time Basal rate (units/hour) Blood glucose (mmol/L)
18:00 0.25 5.4
20:00 0.45 7.3
22:00 0.45 12.1
24:00 0.3 12.2
02:00 0.3 11.8
04:00 0.3 9.4
06:00 0.3 9.2
RiseinBG>2mmol/Lat22:00,soincreasethebasalrate2hoursbeforethisrise.
TDD15.6unitsperday,sochangebasalrateby0.05unitsperhour.
Newbasalrateat20:00=0.45+0.05=0.5unitsperhour.
4. Which insertion sites should be used, and how often do they need to be changed?
Cannulascanbesitedintheabdomen,thighs,hipsortopsofbuttocks.Thereisusuallytoolittlefatonayoungchild'sabdomentousethisasaninsertionsite.
Thecannulaneedstobere-sitedeverytwoorthreedays.
IfyouseetheBGtrendrisingcominguptothethirdday,thenyouwillneedtore-sitethecannulaeverysecondday.Thisismorecommoninyoungerchildren.
Aimtore-sitethecannulabeforeamealsothatyoucanbesurethesetisworking.
Avoidre-sitingthecannulabeforebed,asitwilltakesomehourstoseearisingBGifthereisaproblemwiththenewinsertionsiteandthebasalinsulinisnotinfusing.
Document the basal rate review readings, the date and any changes made in the diary.
Remember to rotate insertion sites – lumpy sites remain a common problem.
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5. What is insulin sensitivity and what should it be set as?
Thisisthesameasa‘correctionfactor’.
Reviewthetotaldailydoseofinsulin(TDD)inutilities.Dividethisnumberinto100.Thisisyourinsulinsensitivity.
For example:
TDD=21units
Insulinsensitivity=100dividedby21=4.7
1unitofinsulinreducestheBGby4.7mmol/L
Thiscanbeadjustedfordifferenttimesoftheday,e.g.overnightmaybe1unitlowersby6mmol/L.
6. What is active insulin, and what should it be set as?
Activeinsulinisthebolusinsulinwhichhasbeendeliveredtoyourbody,buthasnotyetbeenused.Theactiveinsulinsettingmeansthedurationofinsulinaction,orhowlongabolusofinsulinwillremainactiveinthebodyforafteritisgiven.Thisisusuallysetas3hours.
Thiscanonlybecheckedifyouareconfidentthatthebasalratesarecorrect.
Youcanassesstheactiveinsulinprofilewithabolus:checkaBGbeforeameal,iftheBGisintarget,eatalowfatmealwithknownCHOcontent,usingboluswizardtogiveanormalbolus.
ChecktheBGhourlyforupto5hoursafterthemeal.Donoteatordrinkanysnacksorcarbohydratecontainingliquids,anddonotpartakeinanyexerciseoverthisperiod.
ReviewhowlongittakesfortheBGtocomebacktothepremeallevel(+/-2mmol/L).Ifitcomesbacktorangein3hours,activeinsulinshouldbesetas3hoursonthepump.Ifittakesalongerorshortertimetocomebacktorange,theactiveinsulincanbeadjustedaccordingly.
7. What are composite boluses?
Square wave: thebolusisgivenevenlyoveraperiodoftime(setfrom0.5–8hours).
Thisisusefulforhighfatmeals,lowglycaemicindex(GI)foods,orextendedmeals(e.g.buffets).AhighBGbeforethemealneedstobecorrectedwithaseparatenormalbolus.
Dual wave: thisisacombinationofanimmediatenormalbolus,followedbyasquarewavebolus.
ThisisusefulformealswithbothrapidlyandslowlyabsorbedCHO.Whensettingupadualwavebolus,yousetboththepercentageofinsulingivenbynormalandsquarewavebolus,andthetimethesquarewaveisgivenover.AhighpremealBGcanalsobecorrectedwithadualwavebolus.
e.g.50%normalbolus50%squarebolusover4hours.
Seetheexample:Medtronichandbook(page98/99)
Insulin sensitivity = 100 divided by TDD
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Exercise and Activity on Insulin Pump Therapy
Keep a record of what you do, as you will learn what best suits you/your child with time and experience.
When should I check a BG?
Check a BG before exercise
AimforaBG6-8mmol/Lbeforeexercise.
IftheBGis4-6mmol/L,giveasmall‘free’carbohydratesnackbeforeexercise(i.e.donotcoverthiswithabolus).
IftheBGisabove8mmol/Ltherearetwooptions:
1. Giveacorrectionbolus,andthengiveextrafreeCHOfree(seebelow).ThisisthebestoptioniftheBGis>10mmol/L.
2. Donotgiveacorrectionbolus,anddon’tgiveadditionalfreeCHOforbrief/moderateexercise.ThisisthebestoptioniftheBGis8-10mmol/L.
IftheBGis>15mmol/Lwithketones-don’texercise.Followthe‘Hyperglycaemia’flowchart(seepage16).
IftheBGis>15mmol/Lwithoutketones–itisstilloktoexercise,e.g.justafteramealwhenreducedinsulinwasgiveninpreparationforexercise.
Check BG at least hourly during sport
Thismayneedtobemorefrequentsoonafterstartingpumptherapytolearnyour/yourchild’sownresponse.
Check BG after sport
ConsiderreplenishingenergystoreswithadditionalCHO(seeexercisemanagementsection).
How do I manage mild to moderate activity?
Mild or brief activity
Ifexerciseisbriefandmild,donotalterthebasalrates,anddonotremovethepump.SomepeoplefindtheyneedasmallamountofadditionalCHO,e.g.0.25gofCHOperkgofbodyweightperhourofactivity.
Planned moderate activity
Ifexerciseifplanned,youshouldsetatemporarybasalrate.Thereducedbasalrateshouldstart60minutesbeforetheexercise,andcontinueforatleast60minutesaftertheexercise.Thismayneedtobetailoredaccordingtotheresponseinbloodglucose.Weadvisestartingwitha30%reduction(i.e.setas70%temporarybasal),butthiscanvaryfrom10-50%reduction.
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Example 1
Thesunhasjustcomeoutsoyouaregoingtotakeyourchildtotheplaypark,hopefullyforabout1hourifitstaysdry.Yourchildweighs20kg.TheirBGis6.3mmol/Lbeforeyouleavehome.
Whileattheparkyourchildwillbedoingmoderateexercise.
Moderateexercise,soneed0.5g/kg/hrofCHO,i.e.0.5x20x1=10gperhour(or5gfor30minutes)withoutabolus!
Thiscanbeadjustedwithexperienceanddependingonyourchild'sactivitylevelwhileatthepark.
Example 2
Yourchildhasfootballtrainingfrom3.30pmtill4.30pm.Yousetatemporarybasalratestartingat2.30pm(60minutesbeforefootballtrainingbegins),witha30%reduction(setas70%temporarybasal).Yousetthisfor3hours(i.e.60minutesbefore,60minutesduring,and60minutesafterfootball).
Youtestyourchild’sBGjustbeforeyouleaveanditis9.8mmol/L.Thisisabovetarget,butyoudonotgiveacorrectionbolus,asyouknowhehashadlessinsulinforthelast60minutes.YoucheckhisBGafter30minutesoffootballanditis6.8mmol/L,sohehasadrinkofwater.
Justattheendoffootballtraining,yourchild’sBGis4.6mmol/L.Youleavethetemporarybasalonforanother60minutes,andplantocheckaBGatthistime.
Unplanned moderate activity
Ifexerciseisunplanned,ortheduration/intensityisunknown,theonlyoptionistotakeadditionalCHOatthebeginningofandduringexercise.Youshouldalsoseta70%temporarybasalatthebeginningoftheactivity,fortheexpectedlengthofactivity,and60minutesafterwards.Thiscanbecancelledatanytime,forexampleiftheperiodofactivitydoesnotlastaslongasexpected.
Ifexerciseismoderate,consumeadditionalCHO.Approximately0.5gofCHOperkgofbodyweightisneededperhourformoderateactivity.DonotbolusforthisCHO,ifyouhavenotsetatemporarybasalrate60minutespriortoactivitystarting.
Altering bolus insulin with moderate exercise
Ifexerciseiswithin2hoursofameal,thebolusinsulincanbereduced.Thisishelpfulforplannedexerciseofknownintensityandduration.ItavoidstheneedforextraCHOonafullstomach.WorkouthowmuchCHOisneededfortheexercise.SubtractthisamountofCHOfromtheamountduetobeeatenatthemeal,thenbolusfortheremainingamountofCHO.
e.g. Youweigh30kg,andyouaregoingtoexercise(moderately)foronehour.
Moderateexercise,soyouneed0.5g/kg/hrofCHOi.e.0.5x30x1=15gofCHOperhour.
Youareabouttoeatamealcontaining75gofCHO.
Yousubtract15gofCHO(forexercise)from75gi.e.75g-15g=60g.
Youbolusfor60gofCHO.
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How do I manage strenuous activity?
Check a BG before exercise
TheBGbeforestrenuousexercisemustbe5-15mmol/L,ideally5-10mmol/L.ThehigherlimitwouldonlybeacceptableifyouhaveeatenCHOwithoutabolus,orwithareducedbolus,orusedareducedtemporarybasalrateinpreparationforexercise.
Set a temporary basal rate
Consideratemporarybasale.g.30-70%reduction(setas70%to30%temporarybasalrate),beginning60–90minutesbefore,andcontinuing60-90minutesafterstrenuousexercise.
Aperiodof4-8hoursoftemporarybasalrate(50-70%ofusualbasalrate)mayberequiredfollowingexhausting/prolongedactivity,duetotheriskofdelayedhypoglycaemia.
Consume additional carbohydrate
Thismayberequiredinadditiontosettingatemporarybasalrate.Youneedabout1gofCHOperkgofbodyweightperhourofexercise,andthiswouldnotbecoveredwithabolus.ExperiencewillbegainedbyrecordingBG’sduringandafterexercise.IftakinganyadditionalCHO,useareducedboluse.g.50%lessthanwouldusuallybegiven.
Reduce the bolus insulin after exercise
Thebolusinsulinforamealafterstrenuousexercisecanalsobereducedby30-70%,dependingontheactivity–seethe‘ExerciseandSportsection’fordetails.
Can I remove the pump during exercise?
Youcandisconnecttheinsulinpumpduringsportifrequired,forexample,forcontactsports,orduringstrenuousactivitythatyouknowhaspreviouslyresultedinhypoglycaemiadespiteatemporarybasalandadditionalcarbohydrate.
Pumpscanbedisconnectedforuptoonehour.YoumustcheckaBGduringexerciseifthepumpisdisconnected.
Withexperience,longersessionsoffthepumpcanbemanaged.Pleasediscussthiswiththediabetesteam,asfurtherindividualisedinformationisavailable.
Check BG regularly during and after strenuous exercise. Recording BG’s, pump settings and CHO intake will help to guide management of future exercise sessions.
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Notes (A)• Onaninsulinpump,onceBG>4mmol/Lasnackisnotessential.
• IfgivingfoodgiveaninsulinbolusforCHOusingcurrentinsulin:CHOratiousingboluswizard.
• Bolusmaybegivenafterfoodifpoortoleration/vomitinganticipated.
• DonotgiveacorrectionforBG>7mmol/Lfor2hoursafterhypotreatment.IfBG>7mmol/Ltheninput7mmol/Lintothepumptoensureacorrectionisnotgiven.
Notes (B)• Considerreasonbehindfrequenthypoglycaemia,i.e.intercurrentlyunwell,exercise-related,orthereisapatternofhyposdeveloping.
• Ifthereisapatternthenconsidertakingaction,i.e.seekmedicaladviceifunwell,considerlookingattheexercisemanagementroutineorconsidermakingalterationstobasalratesettings.
Give glucose as usual(10g of glucose, or see Hypoglycaemia section page 5)
Wait 10-15 minutes then recheck BG
BG now ≥4mmol/L(See Notes (A) below for further guidance)
Check BG 1-2 hourlyAim for BG target levels 5-7mmol/L
Hypoglycaemia twice in 1 hour OR 3 or more times in 2 hours
(See Notes (B))
Set a temporary basal rate at 50% for 2 hours
After 2 hours – Re-check BGAim for BG target levels 5-7mmol/L
BG remains <4mmol/L
Management of Hypoglycaemia BG <4mmol/L
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<1.0mmol/L
Give correction bolus via pump and re-check blood glucose in 1 hour
BG
Carry on as normal and give further
corrections if required
yes
no
* Correctionbolusviapen:Giveasperthe‘SickDayManagement’flowchart.Youneedtoknowthetotaldailydose(TDD)ofinsulin(inutilitiesmenuonpump).Youwillrequirea10%or20%(ofTDD)correctiondependingonyourbloodglucoseandbloodketones.
**Onceyouhavegiventhepeninjection,disconnectthepumpandsetthepumptodeliverthesamebolusdosegivenbypeninjection.Allowthistorunthroughthetubinganddiscardit(e.g.intothesink/ontothefloor),beforereconnectingthepump.Thismeansthatthecorrectiondosewillbeshownonthepumpdownloads,andincludedinthepump’sactiveinsulincalculation.
no
yes
yes
no
≥1.0mmol/L
1. Give correction bolus via PEN device*
2. Remove pump and run bolus through set**
3. Change pump infusion set
4. Check insulin pump (self-test)
Re-check blood glucose in 1 hour
BG
Re-check blood glucose and blood ketones
in further 1 hour
BG blood ketones
Management of Hyperglycaemia BG ≥14mmol/L
Check ketones
Page 17
Consider temporary basal rate
by further 25%
INSULIN PUMPS PAGE 17
Continue to check BG 2 hourly until levels remain within target and blood ketones are <0.5mmol/L on normal basal rates
Levels reach targetyes
Insulin Pump Therapy During Intercurrent Illness
Blood glucose (BG) level ≥14mmol/L and ketones present Follow Hyperglycaemia Guidelines (page 20)
Blood glucose levels remaining above target Unwell and requiring additional background insulin
Check BG and ketones 1-2 hourly Aim for BG target levels 5-7mmol/L
Set a temporary basal rate at 125% for 2 hours
After 2 hours – Re-check BG and ketone levels
Notes
• Ensureplentyofsugar-freefluidsifthebloodglucoseishigh.
• Ensureadequatecarbohydrateintake.
• Aninsulinbolusmustbegiventocovercarbohydratecontentoffoodandfluids.
• Ifmanagingtoeat,thebolusinsulindosemayneedtobeincreasedtemporarilye.g.ifusuallyusinginsulintoCHOratio1unit:10g,changeto1unit:8g.
no
Consider or stop temporary basal rate
Levels Levels steady
Continue temporary basal
Levels
Page 18
INSULIN PUMPS PAGE 18
Troubleshooting – Pump Failure
What can cause a pump to stop delivering insulin?
• Thebatterycanrunout–thiswillnothappenwithoutwarningandyouhavebeensuppliedwithsparebatteries.
• Thepumpcanbedropped.
• Thepumpcanbedisconnectedbyaccident.
• Insulincanleakoutofagivingsetifitisnotconnectedproperly.
What do I do if I suspect a pump problem?
• Checkabloodglucosereading.
• IftheBGis>14mmol/L,checkforketonesandfollowthehyperglycaemia/intercurrentillnessflowchart.
• Changetheinfusionset.
• Ifatechnicalproblemwiththepumpissuspected,runa‘self-test’.(Dothisifthepumphasbeendropped).
• Ifthisdoesnotresolvetheproblem,removethepumpandswitchtosubcutaneousinsulininjectionsbybasalbolusregimen.
• Contactpumpcompanyfortechnicalhelp.
Page 19
Telephone Advice
General advice
Itisexpectedthattheinformationgivenwhenyoucommencetheinsulinpumpwillallowyoutomanageproblemsthatariserelatingtodiabetes.
Telephoneadvicecanbeobtainedduringnormalofficehoursbycontactingthediabetesnursespecialists(0131 536 0375).
Pleasenotethatadviceregardingthemanagementofinsulinpumpsisnotavailableout-of-hours(i.e.evenings,weekendsandholidays).
Shouldyouencounterdifficultiesthatyouarenotabletosolveusingtheinformationthathasbeenprovided,youshoulddisconnectthepumpandrevertbacktosubcutaneousinsulininjections.
How do I switch from the insulin pump to insulin injections?
Theamountofinsulinrequiredbyinjectiondependsonthetotaldailydose(TDD)ofinsulinonthepump.Thisinformationcanbeobtainedfromthedailytotalsmenuonthepump(utilitiesmenu.
How do I calculate the dose of insulin required by injection?
Option 1Findthecurrenttotaldailybasalinsulindosein‘utilities-dailytotals’menu.Givethisaseitherlantusoncedaily,ordividebytwo,andgiveaslevemirtwiceaday.
Forbolusinsulindoses,usethecurrentinsulin:CHOratiosandinsulinsensitivity(correctionfactor)fromthepump(Novorapid/Humalog).
Option 2Usethelasttotaldailydoseofinsulin(TDD),eitherfromthe‘utilities-dailytotals’menu,thelastdiabetesclinicletter,orarecentpumpdownload.SplittheTDDinto50%basaland50%bolus.Basalinsulincaneitherbegivenaslantusoncedaily,ordividebytwoandgiveaslevemirtwiceaday.
Forbolusinsulindoses,usethecurrentinsulin:CHOratiosandinsulinsensitivity(correctionfactor)fromthepump(Novorapid/Humalog).
Option 3Ifthepumphasfailedandyoucannotaccessthesettings,andyoudonothavearecentdiabetesclinicletter,orarecentpumpdownload,estimatethetotaldailydoseofinsulin(TDD)by:
TDD=Weight(kg)x0.8
Dividethisinto50%basaland50%bolus.Givethebasalinsulinaslantusoncedaily,ordividebytwoandgiveaslevemirtwiceaday.
Ifyoudonotknowthecurrentinsulin:CHOratios,the50%bolusinsulincanbedividedbythreeandgivenateachmeal(Novorapid/Humalog).
INSULIN PUMPS PAGE 19
Page 20
INSULIN PUMPS PAGE 20
Additional very fast acting insulin may be required outside of mealtimes as per the Sick Day Management section.
Example
TDDoninsulinpump 24units
50%basal 12unitsLevemir6unitsinthemorningand6unitsintheeveningORLantus12unitsoncedaily.
50%bolus Usetheinsulintocarbohydrateratioandcorrectionfactorfromthepumpsettingsatmealtimes.Alternatively12units(4unitsatbreakfast,4unitsatlunch,4unitsattea)
Page 21
Admission to Hospital While on an Insulin Pump
Insomesituationsitispossibletocontinueonaninsulinpumpifyou/yourchildare/isadmittedtohospital,howevertheremaybereasonswhyitisdeemedsafertodiscontinuetheinsulinpumpandswitchtosubcutaneousinjectionsduringahospitaladmission.
When is it not possible to continue on an insulin pump in hospital?
Inthefollowingsituationsyou/yourchildmustremovetheinsulinpumpandswitchimmediatelytoinsulinbysubcutaneousinjectionorIVinsulininfusion.
• Diabeticketoacidosis–thepumpwillbedisconnectedandinsulinandfluidswillbestartedthroughaninfusionintothevein.
• Ifyou/yourchildare/isdrowsyorunconscious.
• Ifyou/yourchildare/isseriouslyillandrequireadmissiontotheintensivecareunit.
• Ifthereisnoonecontinuouslypresentontheward(parentorcarer)toperformallpumpcare.
• Ifyou/yourchildhaveamajorpsychiatricdisturbance.
• Ifyoudonothaveenoughconsumables(parentsshouldhaveallconsumablesrequiredforthedurationoftheadmission).
• Othersituationsasdeterminedbythemedicalstaff.
INSULIN PUMPS PAGE 21
Page 22
Guidance for In-patients Remaining on an Insulin Pump
Providingtherearenocontra-indications(aslistedabove)patientsmayremainontheirinsulinpump.Itisexpectedthattheparent/carerwillberesponsibleforthemanagementoftheinsulinpumpatalltimes duringtheadmission.
What documentation is needed for in-patients on insulin pumps?
• Wewillaskyoutosignaformindicatingthatyouwillberesponsibleformanagingyourchild’spumpanddocumentingpumpsettings.
• Wewillaskyoutodocumentthebasalrates,bloodglucose,bloodketones,carbohydrateintakeandbolusinsulingivenondailydiarysheets(thesameasthoseusedafterthepumpstart).
Who will operate the insulin pump on the ward?
• Aparentorguardianmustbeabletostaywiththechildatalltimesduringtheadmission.
• You/yourchildmustoperatethepumpduringtheadmission.
• You/yourchildmustmakeanyadjustmentsonthepump.
• Theflowchartsformanagementofhypoglycaemia/hyperglycaemiaandsickdayswillbeavailableontheward.
What happens if my child needs to have an operation?
Theinsulinpumpmayberemovedforshortprocedures(thetotaltimeoffthepumpshouldnotbemorethan60minutes)suchasforanMRIorCTscan.Iftheprocedurewilltakelongerthan60minutes,itmaybepossibletostayonthepumpwithguidancefromthediabetesteam,butitmaybenecessarytocomeoffthepumpandswitchtoinsulininjectionsoraninfusionofinsulinintoavein.
Radiology investigations
• TheinsulinpumpmustberemovedbeforeenteringtheMRI/CTsuite.ThisisbecausethemagnetintheMRIscannerwillcausethepumptofail.
Minor surgery
• Insulinpumpsmaybeused,continuingonabasalrateduringfastingperiodsandthesurgicalprocedure.
• Thediabetesteamwilldiscusswiththeanaesthetistpriortotheprocedure.Bloodglucosewillbemonitoredhalf-hourlyduringtheprocedure.
• Bolusescanbegiventhroughthepumpasusual,onceeatinganddrinkingaftertheprocedure.
Major surgery
• Thepumpneedstoberemovedandaninfusionofinsulinthroughadripintotheveinwillbecommenced.
INSULIN PUMPS PAGE 22
Page 23
Parent/Carer Consent Form
Continuation of insulin pump therapy during in-patient stay
Foryourchild’ssafetyduringthisadmission,werequestthatyouagreetothefollowingrecommendations.Ifyoufeelthatyoucannotagreetotheserecommendations,wewouldliketotreatyourchild’sdiabeteswithinsulininjectionsandrequestthatyoudiscontinuetheuseofyourchild’sinsulinpump.
As the parent/carer during my child’s admission to hospital:
• Iamtrainedtousetheinsulinpumpandwillremaininthehospitalforthedurationoftheadmission.
• Iwillmanagetheinsulinpumpduringtheadmission.
• Iwillprovidealltheequipment,consumablesandinsulinrequiredforthedurationoftheadmission.
• Iwillrecordthepumpsettings,basalrates,bloodglucose,ketones,carbohydrateintake,insulinbolusesonthe‘insulinpumpin-patientrecord’chartwhichwillbekeptintheyellowfolderbythebedside.
• Iwillallownursingandmedicalstafftohaveaccesstothe‘insulinpumpin-patientrecord’atalltimes.
• Iwillchangetheinfusionsetevery48–72hoursorasrequiredaccordingtothehyperglycaemiaorintercurrentillnessflowchart.
• IfIcannotmanagethepump,theinsulininfusionpumpwillbedisconnectedandinsulininjectionscommenced.
I also understand that the pump may be discontinued and a different insulin delivery given for any of the following:
• Contra-indications(aslistedabove).
• Therequestoftheconsultantresponsibleforthepatientduringtheadmission.
• Anx-rayprocedure(mayincludepumpremovalbytubingdisconnectand/orremovalofthepumpandtubing).
Parent/Carer
Signature............................................ Print................................................. Date...................
Witness
Signature............................................ Print................................................. Date...................
INSULIN PUMPS PAGE 23