Insulin Pumps (And CGM) Kim Johnson - neusha.org · 7/11/2017 1 Insulin Pumps (And CGM) Kim Johnson...
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Transcript of Insulin Pumps (And CGM) Kim Johnson - neusha.org · 7/11/2017 1 Insulin Pumps (And CGM) Kim Johnson...
7/11/2017
1
Insulin Pumps (And CGM)
Kim Johnson RN, CDE
UMass Memorial Medical Center
What do you think?Sally is a 15 year old girl with type 1 diabetes for 6 years. She is a freshman in high school and very involved in sports. Sally has maintained HgbAlc levels between 7.6 and 8.3%, but over the last year her HgbAlc has risen to 9.7%. Sally and her Mom feel managing her diabetes would be easier with a pump.
1. Because her glycemic control has worsened Sally should switch to a pump to achieve better control.
2. Because her control has worsened she is demonstrating that she is not able to manage her diabetes and should not get a pump.
3. Further evaluation is needed to see if Sally could benefit from an insulin pump
4. Because of her involvement with sports, Sally would not be a good candidate for pump use.
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What is an Insulin Pump?
A small computerized device that delivers insulin continuously throughout the day
Programmed for each individual wearer
NOT an artificial pancreas …. wearer still has to tell the pump what to do
History of Continuous Subcutaneous Insulin Infusion: Insulin Pumps
1960s
1970s
1990s
1980s
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Insulin Pump ‐ Catheter
Insulin Pump features• Designed to operate at environmental temperatures between
32° and 104° F (not insulin: stable up to 86° F)
• Some say waterproof, ?
• Specific features– integrated glucometers (wireless)
– Integrated glucose sensors
– personalized carbohydrate and correction factors (bolus wizard)
– tracks residual bolus insulin
– missed bolus reminder
– child lock
– stores CHO content of common foods
– remote access
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Todays Pumps
MEDRONICDIABETES
TANDEM DIABETES CARE ANIMAS CORP.
INSULET CORP.
Continuous Glucose Monitoring
Continuous Glucose Monitoring uses a sensor that monitors glucose levels in the interstitial fluid
The Dexcom sensor provides a continuous reading and can be worn for 7 days
CGM helps identify trends, alerts when blood glucose is high or low, and can show how fast levels rise or fall
Three parts:◦ Small Sensor this sits under the skin◦ Transmitter A piece that fits in the sensor and sends data to display device
◦ Display Device Can be seen on the Dexcomreceiver, a pump, a tablet orphone.
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Needed for Pump Success:Motivated and Motivation
Everyone must want pump (not just the pump wearer, but the whole team (family, physician)◦ Team approach and family support is so important
Demonstrate a competent diabetes care skill set◦ Problem solving
◦ How to treat highs, lows, ketones, pattern managment
◦ Ability to count carbs◦ Back to nutrition for review
◦ Willingness to check blood sugars 4‐6 X day◦ NO EXCUSES
No Alc or age criteria
‐ Precise Dosing
◦ 0.025 units
‐ Adjustable Basal rates
‐ Immediate Access to insulin
◦ Extended bolus for high fat/ high Carb foods
‐Match insulin to food and exercise
◦ Increase, decrease or stop insulin as situations demand
‐ Pumps manage Insulin on Board (IOB)
◦ Tells you how much insulin you still have on board
◦ Avoids insulin stacking
‐ Fewer Pokes
◦ Q 2‐3 days
◦ Need to use a variety of injection sites
Vs.‐ NO Safety NET
‐ Increased Risk of Hyperglycemia and DKA
• Crimped infusion sets
• Air bubbles
• Clogs in the cannula
• Needle bends
• Cannula Pulled out
‐ Higher potential for skin abscess or infection
‐ Learning Curve
‐ $$$$
‐ Constantly attached to pump
‐ Clothing adjustment
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Pump Terminology
Basal: Continuous rate of Insulin delivered◦ Injections think Long‐Acting Insulin like Lantus, Levemir, Or NPH
Bolus: Amount of insulin given to cover high blood glucose levels or carbs eaten ◦ Injections think Novolog, Humalog, Apridra, regular or rapid acting insulin
Insulin to Carb ratio: How many units of rapid acting insulin is needed to cover carbs eaten
Correction Factor (Sensitivity Factor): How much one unit of insulin will bring down a blood sugar
Target: A number in the middle of where we want child’s blood sugar to be (I.E. 80‐180 mg/dl: target = 120 mg/dl)
Infusion Set:◦ Narrow, flexible tubing that connects the pump to the person
Cannula:◦ Tube at the end of an infusion set that is inserted just under the skin (Straight Vs. Angle)
http://www.clipartpanda.com/categories/diabetes‐clip‐art‐pictures
BASAL Vs. BOLUS:Dosed in units per hour
Continuous infusion of fast‐acting insulin
◦ Background insulin
◦ Replaces Long acting insulin like Lantus
Food doesn’t factor into this dose
Activity CAN factor into this dose
Example basal rates:
◦ Ensure am/pm correct
Time Rate
12:00‐3:00 am 0.45 units/hour
3:00‐9:30 am 0.35 units/hours
9:30 am‐1:30 pm 0.40 units/hours
1:30 ‐7:30 pm 0.35 units/hour
7:30 pm‐12:00 am 0.25 units/ hour
• 2 Types
• Food:
• Used whenever food is eaten
• Uses carb/insulin ratio
• Correction:
• Insulin used to bring down high sugars
• Uses target and correction/sensitivity numbers
• Calculating BOLUS:
• Insulin: Carb ratio
• Correction Blood Glucose‐Target Blood Glucose/ Insulin Sensitivity Factor
• IOB X Insulin action time (EX: Humalog onsets within 15 minutes/peaks at 30‐90 minutes/ duration is <5 hours)
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IOBAccounts for amount of insulin still active in the body from previous bolus ◦ Insulin that has been delivered but not completely used yet
Prevents Insulin “Stacking”◦ When you take too many bolus doses without letting prior doses run‐out
Allows for more accurate bolus dosing
Usually set at 3‐4 hours
Insulin Pumps Complications: Minor• Infusion site
– Lipodystrophy ‐ hypertrophy ‐ tissue buildup caused by injecting insulin repeatedly into the same area; these areas should be avoided until it clears, Atrophy ‐ a loss of tissue
– Site preparation ‐must be clean and dry before inserting the needle
– Antiseptics ‐ ~ 1 in 10 is prone to developing infections at the infusion site; antiseptics (i.e. betadine, hibiclens)
– Skin irritation – sensitivity to tape or plastic part of infusion set
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Insulin PumpsMinor complications ( continued)
– No delivery alarm (caught early)
• Clog or kink in infusion system
• Problem with infusion site
• Insulin reservoir may be empty
• Recommend checking blood sugar, check ketones (if necessary), give insulin injection (if necessary) and change infusion set
– Pump malfunction (caught early)
• Pump company 24‐hour help line
• Usually send out replacement the next day
• Resume SQ insulin injections (call endocrinologist for specific dosing)
Insulin PumpsMajor complications
– No insulin delivery (not recognized)• Patients can develop diabetic ketoacidosis (DKA) within 4‐10 hours after discontinuation of insulin
• Often occurs overnight during sleep; patient awakens with vomiting, ketones, and hyperglycemia
• Symptoms can be mistaken for the “flu”
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Avoiding DKA on a Pump:
If BS is over 240 then…◦Check for Ketones (a byproduct of burning fat)◦ Trace ketones:◦ take a correction with insulin and drink plenty of water
◦Moderate to Large Ketones (ASSUME IT IS THE SITE) contact DM team/parent◦ Take correction (10 – 20 % of TDD)with SYRINGE or PEN (not the pump) and change site immediately ◦ Never assume a new site = a good site
◦ Recheck blood sugar and ketones in two hours
So your student has an insulin pump ‐What do you need?
◦ Supplies:
◦ BG test strips
◦ ketone test strips
◦ Treatment for hypoglycemia, oral and glucagon
◦ Insulin, syringe/pen
◦ Infusion set (who will change this if needed, what is the fill cannula volume)
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What information should you be able to find in the pump?‐ Battery life
‐ Amount of insulin available
‐ Basal rate
‐ Bolus information ‐ Insulin/carb ratio, sensitivity, target BG
‐ Bolus history
‐ Total daily insulin
Following BG patterns
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So, back to Sally What do you want to knowWho does procedures?
How many blood sugars are they doing?
Do they look at BG patterns?
Do they count carbs?, correctly?
Are there any weight or body image issues?
What is the level of involvement of parents?
Other supports? Do her friends know she has diabetes?
Does she carry supplies?
Who wants the pump? Why?
So, back to Sally What do you want to knowWho does procedures?
How many blood sugars are they doing?
Do they look at BG patterns?
Do they count carbs?, correctly?
Are there any weight or body image issues?
What is the level of involvement of parents?
Other supports? Do her friends know she has diabetes?
Does she carry supplies?
Who wants the pump? Why?
Usually Sally
2 to 3 per day, often misses pre lunch and bedtime
No written record or downloading
Yes, but guestimates
None noted at this time
Sally is doing procedures, Mom was not aware of her dosing
One friend knows of her diabetes
Generally no, will sometimes miss insulin if eating out with peers
Both say they do, “easier”
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Thank You