Putting Pump Policies Into Practice- Case Study Conference Call

Elizabeth Blair, ANP-BC,CDE

Joyce Lekarcyk, RN, CDE

Objectives:

Able to assess probable causes of hypoglycemia and hyperglycemia

Able to interpret data to make changes in pump settings

Able to identify other technologies available to determine insulin adjustment

Assessment Tools

Assessment should include evaluating the following:

Total daily dose- % of basal vs. bolus Evaluating I:C ratio and sensitivity factor Evaluating basals rates Trouble shooting, insertion sites, insulin

usage, technique Glucose records can be used to determine

whether the cause of hyperglycemia or hypoglycemia is related to basal vs. bolus

Basal vs. Bolus- Tips to decide

Probable causes of hypoglycemia:

Bolus Timing of bolus Stacking Carb counting vs. estimating Food choices Alcohol Activity New sites Basal rate

Probable causes of hyperglycemia:

Bolus Timing of bolus Grazing Carb counting vs. estimating Food choices Alcohol Activity Set change Basal rate Technique vs. compliance

When and why does it happen?

Case Study John O

John has had Type 1 diabetes for 30 years The last 5 years he has been using a

Medtronic insulin Pump 522 Three vessel CABG 9 years ago

Hypoglycemic unawareness TDD: Basal: 14.6 Bolus: 27 to 36 units A1c 7.3%

Day 1 12 AM

3 5 6 7 8 9 10 11 12 PM

1 2 3 4 5 6 7 8 9 10 11

BG

44 121 178 190 156 123 84 68

Carb grams

28 25 25 25

Meal Bolus

5.6 5 2.9 5 5

High Bolus 2.1 2.1 2.8 Basal Rate .1 .6 1 .8 .45 1 .4

Initial record review

Day 1 12 AM

3 5 6 7 8 9 10 11 12 PM

1 2 3 4 5 6 7 8 9 10 11

BG

44 121 178 190 156 123 84 68

Carb grams

28 25 25 25

Meal Bolus

5.6 5 2.9 5 5

High Bolus 2.1 2.1 2.8 Basal Rate .1 .6 1 .8 .45 1 .4

Initial record review

Initial record review

Day 2 12 AM

5 6 7 8 9 10 11 12 PM

1 2 3 4 5 6 7 8 9 10 11

BG

114 285 204 110 147 64 71 77

Carb grams

22 10 25 21 10

Meal Bolus

4.4 2 5 3.1 2.0

High Bolus

3.4 6.9 2.5

Basal Rate

.1 .6 1 .8 .45 1 .4

Initial record review

DA Y 3 12 AM

3 5 6 7 8 9 10 11 12 PM

1 2 3 4 5 6 7 8 9 10 11

BG

111

93 181 178 204 182 109 70 123

Carb grams

26 20 25 23

Meal Bolus

5.2 4 5 4.6

High Bolus 4.1 3.1 .9 Basal Rate .1 .6 1 .8 .45 1 .4 .1

Pump Settings

Pump settings: 1:5 ratio SF: 30 Target glucose: 95

Basal 12a - 0.1 3a - 0.6 5a – 1.0 6a - 0.8 12p - 0.45 8p - 1.0 10p - 0.4

Your answers

Why?

Your answers

Which pump settings should you question?

a) IC ratio and SF

b) Target glucose

c) Basal rates

d) all of the above

Your answers

What pump setting would you change first?

a) Recalculate basal rate based on TDDb) Recalculate IC ratio and SF c) Wait for more trendsd) Change glucose targete) All except for c

Tools to use

Recalculating IC ratios and SF

IC ratio- TDD divided by 450

Sensitivity factor: TDD divided by 1500

Any other way to change ratios?

Adjusting Bolus Rates per Policy PC-142

If BG is > than target for 2 days at the same time: increase the IC ratio:

Example: Change 1:15 to 1:12

If BS is < than for les than target for 2 days at the same time: decrease the IC ratio:

Example: Change 1:15 to 1:18

Recalculate basal based on TDD

Possible basal:

Average TDD=49

X .50 = 24.5 divided by 24=1.0 per hour

1500 divided by 49 =SF of 30

450 divided by 49 =IC ratio of 9

Compared to current basal:

14.7 units per day IC ratio of 1:5 Sensitivity factor of 30

First priority - Prevent the low’s

Initial changes:I:C Ratio 10-10-9

SF: 40 Target:120

Basal: 12- 0.4

3- 0.6

5- 1.0

6- 0.75

11-0.8

6p-1.0

10p-0.4

Current rates: 1:5 ratio SF: 30 Target glucose: 95 Basal 12a - 0.1 3a - 0.6 5a – 1.0 6a - 0.8 12p - 0.45 8p - 1.0 10p - 0.4

BG records can only tell you so much! Is there a better way?

First Change: Overnight Basal Evaluation

Overnight FAST

12 AM

3 5 6 7 8 9 10 11 12 PM

1 2 3 4 5 6 7 8 9 10 11

BG

129 125 239 213 197 127 161

Carb grams 47 32 Meal Bolus High Bolus 4.7 3.2 Basal Rate .4 .6 1.0 .75 . .8 1 .4

OVERNIGHT FAST

12 AM 3 5 6 7 8 9 10 11 12 PM

1 2 3 4 5 6 7 8 9 10 11

Lab BG

161 142 168 134 204 268 286 93 164

Carb grams

25 46

Meal Bolus 2.5 4.4 High Bolus 3.7 .6 2.8 Basal Rate .4 .6 1.0 .75 .8 1 .4

Basal rate change

After reviewing overnight Basal results would you:

a) Increase the basal rate by 0.1 at 5am

b) Make no change

c) Consider changing supper IC ratio

d) Increase basal from 10 to 2 by 0.1

Morning Fast

MORNING FAST

12 AM

5 6 7 8 9 10 11 12 PM

1 2 3 4 5 6 7 8 9 10 11

BG

138 174 176 200 186

Carb grams Meal Bolus High Bolus Basal Rate .4 .6 1.0 .75 .8 1 .4 .4

Morning basal evaluation

What changes would you make after reviewing the morning basal evaluations results?

a) Make no changes and repeat the fast

b) Increase the basal by 0.1 at 8am

c) Ask about activity

d) A and C

Lunch Fast

LUNCH FAST

12 AM

5 6 7 8 9 10 11 12 PM

1 2 3 4 5 6 7 8 9 10 11

BG

204 93 103 121 138 145 160

Carb grams 38 Meal Bolus 3.8 High Bolus 2 Basal Rate .4 .6 1.0 .

75

..85 .8 1 .4

Lunch basal evaluation

What changes would you make after reviewing the lunch basal evaluation results?

a) Make no changes

b) Increase the basal rate by 0.1 at noon

c) Increase the basal rate by 0.1 at 2pm

d) Increase the basal rate by 0.2 at 2pm

Evaluating Morning Bolus

EVALUATING MORNING BOLUS

12 AM

5 6 7 8 9 10 11 12 PM

1 2 3 4 5 6 7 8 9 10 11

BG 119 149 132 Carb grams 30 Meal Bolus High Bolus Basal Rate .4 .6 1.0 .85 .8 .9 1 .4 1

“My latest sugars still need a little work”

DATE 12 AM

5 6 7 8 9 10 11 12 PM

1 2 3 4 5 6 7 8 9 10 11

BG

112 128 139 88 137 205 188 231 76

Carb grams Meal Bolus 2.1 3.8 7 3.5 High Bolus Basal Rate .4 .6 1.0 .85 .8 .9 1 .4 1

DATE 12 AM

5 6 7 8 9 10 11 12 PM

1 2 3 4 5 6 7 8 9 10 11

Meter BG

82 135 172 205 360 275 242 203 184

Carb grams 15 3 Meal Bolus 4.1 2.5 5.1 8.3 4.3 High Bolus 2 Basal Rate

Your intervention

In order to prevent the glucose spike after lunch what would you do first?

a) Ask if his meals have change

b) Nothing-wait for more trends

c) Suggest doing a lunch bolus evaluation

d) a and c

“I had a cortisone shot and my sugars are high”

John gave his glucose by phone 24 hours glucose readings ranged

from 200 to 350 mg/dl Infusion set and insulin were changed Ketones-small

What Sick Day Management Guidelines would you give?

a) 50% increase in basal rate for 4 hours

b) 10% of total daily dose via pumpc) 20% of total daily dose via syringe d) Either a or b

Your intervention

Lunch bolus evaluation

John ate 30 gms of carbohydrates:

Glucose before lunch was 100Glucose 3 hours later was 200

Your intervention

What pump setting change would you make?

a) Change I:C to 9 from 10

b) Inquire about activity and what he ate

c) a and b

d) Increase basal 0.1 at 1 pm

Pumping is less challenging to patients when there is a team approach and plenty of follow-up!

Stay tuned to submit a final evaluation of this presentation !