Pumping Basics Pumping Basics Start For Success Start For Success Children With Diabetes Children With Diabetes La Jolla, CA Oct. 3, 2009 La Jolla, CA Oct. 3, 2009 John Walsh, PA, CDE John Walsh, PA, CDE Advanced Metabolic Advanced Metabolic Care + Research Care + Research 700 West El Norte Pkwy 700 West El Norte Pkwy Escondido, CA 92126 Escondido, CA 92126 (760) 743-1431 (760) 743-1431 The Diabetes Mall The Diabetes Mall (619) 497-0900 (619) 497-0900 [email protected][email protected]
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Pumping Basics Start For Success Children With Diabetes La Jolla, CA Oct. 3, 2009 John Walsh, PA, CDE Advanced Metabolic Care + Research 700 West El Norte.
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Pumping BasicsPumping BasicsStart For SuccessStart For Success
Children With DiabetesChildren With DiabetesLa Jolla, CA Oct. 3, 2009La Jolla, CA Oct. 3, 2009
John Walsh, PA, CDEJohn Walsh, PA, CDE
Advanced Metabolic Care Advanced Metabolic Care + Research + Research
1:00 AM 2:00 AM 3:00 AM 4:00 AM 5:00 AM 6:00 AM 7:00 AM 8:00 AM 9:00 AM 10:00
AM
11:00
AM
12:00
PM
1:00 PM 2:00 PM
glucose (mg/dl)
Insulin pumps reduce both glucose exposure and variability
Exposure or Average =
Variability or Swing =
A1c or avg. BG from meter
Standard deviation or GlycoMark test
Many Things Affect The Glucose
Dawn Phenomenon
Eating
InsulinAmylin
Exercise
Insulin resistance
Stress
No Blame For Maximum Gain
• Diabetes is a daily challenge
• Many things change the glucose
• Management can be confusing and difficult
• So:
Focus on problem solving for best results
Positive discipline is needed – kids and teens need regular monitoring (glucose and parental)
Pump Advantages
More reliable, precise insulin action Ease of use (fewer missed doses) Less insulin stacking Fewer lows, especially at night Easier to exercise Less glucose exposure and variability Less insulin Matches variable basal insulin need Less social limitation Better data access for HCPs and parents
A pump’s basals and boluses provide a better match
Bolus
Flexible basal from pump
Basals And Boluses From Pump
“Flat” basal from Lantus or Levemir
Basals And Boluses
A pump’s basal delivery provides a better match for life’s needs
Temp basal reductionfor exercise
Better Control Of Dawn
Glucose levels between 2 and 8 am in 12 type 1 diabetics (mean age: 30 ± 2 years; mean diabetes duration: 11 ± 2 years; HbA1: 8.9 ± 0.3 ) on pumps compared to 8 healthy probands
Graphic from http://www.insulinpumptherapy.co.uk
Less BG Variability, Less Insulin
Graphic from http://www.insulinpumptherapy.co.uk
CSII vs MDI in Adolescents
• “Insulin pump therapy is an effective alternative to injection therapy in a large paediatric diabetes clinic setting. Even very young patients can utilise CSII to safely lower HbA1c levels”.
• “Improved diabetes control was achieved without increasing daily insulin doses and with a decrease in the frequency of severe hypoglycaemic events (p=0.05 vs prepump, all three ages combined)”.
• “Significant and consistent reduction in mean HbA1c levels after 12 months of CSII. (p=<0.02 vs prepump)”.
• “Remarkable effectiveness of CSII in our youngest patients indicates that child’s age should not be a barrier”
1” tape on infusion line:• Stops movement of Teflon under the skin
• Stops “unexplained highs” from insulin leaksto skin surface
• Less irritation
• Prevents pull outs
• Tugs on Teflon
Lose tape not insulin!
No anchor!
Tapes
1” tapes Micropore
Durapore
Hypafix
Blenderm
Tackies
Toupee glue
Skin-Tac
Mastisol
Remove with Goo Gone or Detechol
Sterile Technique For Site Prep
Methicillin-resistant staph aureas (MRSA) is common – 30% of people are constant staph carriers and 25% intermittent.
PREVENT infection:
• Wash hands
• Don’t breathe on site
• Sterilize skin with IV Prep
• Place bio-occlusive IV3000 over site
• Insert infusion set through IV 3000
Staph carriers can reduce or eliminate staph: • Use antiseptic soap over entire body once every 1-2 weeks
• Periodically, apply bacitracin ointment to inside of nose
Pump Start
Prepare
• Use basal/bolus approach with injections
• Count carbs accurately
• Read Pumping Insulin & manual
• Practice with pump as soon as it arrives
• View DVD as you practice with your pump
• Get training in operation andtroubleshooting
Smart Pumps Arrive Dumb
• Pump settings must be individualized
Basal rates, carb factor, correction factor, DIA
• For good boluses, the bolus calculator needs
Current BG value
Accurate CHO counting
• Don’t become too dependent on your bolus calculator
• Use temp basals, combo boluses, etc. for appropriate situations
Both critical
Prepare
• When to discontinue the long- acting insulin
• Prescriptions for insulin, test strips, IV Prep, IV 3000 dressings, etc.
• Contact info (phone, email) for MD, CDE, pump company, pump rep, other pumpers
Initial Pump Settings
• TDD (total daily insulin dose)
• Basal/carb bolus balance
• Carb factor
• Correction factor
• DIA
Steps For Success
• Test often
• Keep records (Smart Charts, download, etc)
• Find your optimum TDD Start basals as half of optimized TDD
Determine starting carb factor with 450 Rule (450/TDD) and correction factor with 2000 Rule (2000/TDD)
• Use a realistic DIA – 4 to 6 hrs
• Find & solve reasons for highs and lows
• Change infusion sets on schedule and when unexplained highs occur
Steps To Control
• Stop lows first
• Take a bolus for every bite Except for carbs used to treat a low BG
Or for carbs used to compensate for exercise
Check BG before every bolus – Stop blind bolusing
• Bolus 15 to 30 min before meals if possible
• Periodically check basal/carb bolus balance
• Look for and correct unwanted patterns
Stop Lows First
Frequent lows show this person needs less insulin with new basal rates, carb factor and correction factor derived from this Optimal TDD.
Red line = 80 mg/dl (3.3 mmol)
XXX
XX X
X = highs caused by
lows
X
Your TDD Needs To Change For
• Changes in diet
• Loss or gain of weight
• Seasons
• Changes in activity
• Seasonal sports
• Vacations
• Growth spurts
• Puberty and menses
Don’t wait til the next doctor’s visit!
Recommended DIA Times
Set DIA to 4.5 to 6 hrs for accurate calculation of BOB and bolus doses
5 hr Linear
5 hr Curvilinear
Adapted fom Mudaliar et al: Diabetes Care,
22: 1501, 1999
Duration Of Insulin Action (DIA)
4 hrs 6 hrs2 hrs0
Accurate boluses require an accurate DIA
Glu
cose
-lowe
ring
Activ
ity
DIA times less than 4 to 7 hrs hide the glucose- lowering activity of boluses
More On DIA
Large doses (0.3 u/kg = 15 u for 110 lb. person) of “rapid” insulin in 18 non-diabetic, obese people
Med. doses (0.2 u/kg = 10 u for 110 lb. person)
Apidra product handout, Rev. April 2004a
Regular
DIA Tips
• DIA times NOT different between children and adults
• If your pump does not “give enough bolus insulin”, do NOT shorten the DIA to get larger boluses
• Look for the real reason:
a basal rate that is too low
or a carb factor too high
that makes your DIA SEEM SHORT!
Basal RatesKeep the glucose flat overnight
or when a meal is skipped after the DIA time has passed
Easy to check – don’t eat
See See Pumping InsulinPumping Insulin 4th ed, 2006, for details4th ed, 2006, for details
How Many Basals?
Percentage of pumpers who use 1 to 10 basals per day from self reports of several hundred pumpers at insulin-pumpers.org%
One basal rate may work in children, while the complex metabolism of puberty often requires multiple rates in teens
• 50% Rule: basals usually make up 40 to 65% of an accurate TDD
• Basal rates will be similar through the day, such as between 0.45 and 0.7, or between 1.0 and 1.4
• For basal rate adjustments, modify in small steps – usually 0.05 or 0.1 u/hr
• Change basals 3 to 8 hours before need arises
• Don’t stop (suspend) pump longer than 30 min.
Basal Tips
Duration Of Carb Action
Most carbs affect the BG only 1 to 2.5 hours
More delay with complex carbs, more fiber, more fat, etc
Thanks to Gary Scheiner, MS, CDEThanks to Gary Scheiner, MS, CDE
Most Carbs Faster Than Insulin
Time over which a bolus lowers the BG
From From Pumping InsulinPumping Insulin
Take Home: Bolus 15 to 30 minutes before meals Use extended boluses sparingly.
Meal’s impact on BG
One hour after a meal, half a meal’s glucose rise is gone, but 80% of the “rapid” insulin’s activity remains
Bolus Timing
Figure shows rapid insulin injected 0 min, 30 min, and 60 minutes before a meal
Normal glucose and insulin profiles are shown in the shaded areas
Carb & Correction Factors
Starting carb factor:
Carb Factor = 2.5 X Wt(lb)/TDD
Starting correction factor:
Correction Factor = 1900/TDD
Regular Taken immediately –MOST meals
Combo / dual wave Some now, some later – good for burritos,
pastas and pizzas, Symlin, Byetta, precose
Extended / square wave All extended over time – gastroparesis
Carb Boluses
Missed Boluses Lead To High A1cs
• One missed bolus a week raises A1c almost 0.5%
Don’t miss boluses:
• Give a bolus for every bite!
• Use pump reminders
• Review pump history to increase number of boluses given each week
• Solve without blame
48 youth in poor control (A1c > 8%). All put on a Deltec Cozmo pump, with half using reminders. Significant reduction for reminder at 3 mos but no difference after 6 mos.
H. Peter Chase et al: Diabetes Care 29:1012-1015, 2006
Carb Bolus Tips
• Does your carb factor work for LARGE carb meals, such as for a carb intake = half your weight in lbs?
• Do you count carb accurately?
• Do you give boluses 20 min before meals when your glucose is normal?
For frequent lows after meals –> raise carb factor #
For frequent highs after meals –> lower carb factor #
Bottom Line
If your smart pump does not give you great control:
Check your pump settings
Check when and how you bolus
And check your infusion sets.
Wrap Up
• Pumps offer best technology for precise insulin delivery
• A more flexible and healthier life with less hypoglycemia
• Requires commitment, responsibility
• But good training and follow-up are required for an effective outcome
• So make the commitment to good health
• And pump well!
The Future
• Pump technology continues to advance
• On the horizon: Pumping and monitoring by cell phone