2014 typeonenation pump talk for nurses austin, texas june 21
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Advanced Insulin Pumping(getting your pump to perform its best)
Stephen W. Ponder MD, FAAP, CDEProfessor
Texas Tech Health Sciences Center
Advanced pumping prerequisites
1. Advanced pumping without solid pumping basics is like building a mansion without a foundation!
2. Work towards mastering the art of “glycemic load” combined with your unique responses…know your food!
3. You steer your own course through the choppy waters of tight blood sugar control…it’s all about choices and process.
The “mother of all pump settings” is the
total daily dose! (TDD)
The 5 basic pump settings
1. Basal rate(s)
2. Insulin on board
3. Target BG(s)
4. Insulin to carb ratio
5. Correction factor
1 or more
2-8 hours (3-5)
1 or more (or a range)
1 or more
1 or more
REMEMBER: K.I.S.S.
Reviewing the rates and ratios
Insulin to Carb (I:CHO)
Insulin Sensitivity (correction) factor
Basal rate profile(s)
TDD⁄500
TDD⁄1800
12M – 3AM
3AM – 7AM
7AM – 12M
40-60% of TDD
0.7U/h
1.0U/h
0.85U/h
Example:
Doing an at home pump “pit stop”
Check pump timeDownload/review bolus
history (time?)
Download/review meter and/or log book (time?)
Review basal ratesCheck for bubbles Inspect infusion site
Ponder’s Pumping Principles
I. A pump is no better or worse than the human being attached to it
II. Glycemic variability is the NORM in diabetes: it’s a matter of how much!
III. Age is not a limiting factorIV. A good pump doc is more a
coach (educator) than a prescriber
V. Simple is always a good start
Ponder’s Pumping Principles
VI. Quality diabetes self care is more of a PROCESS than it is an OUTCOME
VII. Hardware and software change: people don’t
VIII. Consistency is a virtueIX. Success is relativeX. Don’t ever be afraid to start
over
Common pump management errors
• Failure to recognize need for changes– Not reviewing BG, A1c
or pump history data– Patient-related errors– Update pump settings
• Failure to provide on-going educational support
Good Control
Inaccurate carb counting Missed boluses Fear of hypoglycemia No BG input from user Lack of diabetes education Outdated pump settings The imprecision inherent in
pump settings
Weak links to good control with the insulin pump
Good Control
Know where the challenges are…
1. Overnights
2. Early mornings
3. Afternoons
4. Missed/skipped boluses
5. Over-bolusing
6. Adolescent “resistance”
7. Toddler hypersensitivity
8. Fix lows first
Know where the challenges are…
1. Overnights
2. Early mornings
3. Afternoons
4. Missed/skipped boluses
5. Over-bolusing
6. Adolescent “resistance”
7. Toddler hypersensitivity
8. Fix lows first
1. ↓ insulin need @ 2-4 AM
2. ↑ insulin need @ 6-9 AM
3. ↓ basal need mid-afternoon
4. More common in ♀ teens
5. More common in ♂ teens
6. Higher basal % in teen years
7. Lower basal % needed
8. Lows beget highs!
~2AM to 4AM is the biologic low point for insulin need
~ 40% of hypoglycemia occurs during sleep! It’s often asymptomatic!
Bre
akfa
st
Lu
nch
Sn
ack
Su
pp
er
Sn
ack
bolusbolus
bolus
2 -
4 A
M
Bre
akfa
st6
– 9
AM
Sn
ack
0.75U/hr
Basal rates
0.5 U/hr
1.0 U/hr
Midnight
3 AM
6 AM
B A S A L
timetime
Programmed for the “typical” day
Stop Lows FirstBetter control and more stability
• Mild lows cause followup
lows • Small epinephrine release
makes muscles sensitive to insulin
• Can lead to another low as much as 36 hours after the first
• More carbs than usual are needed
Severe lows cause highs
Higher stress hormone release makes glucose rise for 6-10 hrs
Excess carb intake leads to highs
Boluses may be reduced/skipped
More insulin than usual needed
To stop lows, lower the TDD!!!
10 advanced pumping tips1. Basal and bolus self
review/checking
2. Extended boluses
3. Combination boluses
4. The “Sleep bolus”
5. Superbolusing
6. Temporary basal rates
7. Alternate basal profiles
8. Surgery and the pump
9. Bridging the gap
10.Do a pump “pitstop”
. . ..
..
..
..
2 hours150 mg/dl
80 mg/dl
135 mg/dl
glu
cose
0.75 U/hr B A S A L
timetime
94 mg/dl
Testing a basal segment
145 mg/dl
2 hours 2 hours
105 mg/dl
fasting
. . ..
..
.
..
.
..
2 hours155 mg/dl
95 mg/dl
125 mg/dl
glu
cose
0.75 U/hr B A S A L
timetime
60 mg/dl
Bolus for a measured amount of carbs
Testing a bolus
145 mg/dl
215 mg/dl
6
time
0.75 U/hr
Insulin to Carb [I : CHO] ratio
B A S A L I N S U L I N
. . ..
..
.
..
.
..
2 hours
time
180 mg/dl
80 mg/dl
125 mg/dl 150mg/dl
Example: 1 to 10
60 grams CHO / 10
60 / 10 = 6
6
“Acceptable” = “target” +/- 30 mg/dl
glu
cose
bo
lus
CH
O
5
time
0.75 U/hr
“Correction” dose
B A S A L I N S U L I N
. . ..
..
.
..
.
..
2 hours
time
180 mg/dl
80 mg/dl
250 mg/dl
110 mg/dl
Example: 1 to 25
Actual – target / 25
250 – 125 / 25 = 5
5
“Acceptable” = “target” +/- 30 mg/dl
glu
cose
bo
lus
Two week pumper log sheet
(complete the open spots)
Influenced by basal
Influenced by boluses
Checks overnight basal(s)
0.75 U/hr
“Extended” bolus
8 Units
60 minutes
B A S A L
timetime
Best used for grazing-like feeding (e.g., long banquets, receptions, salads, etc…)
Which of the following foods IS NOT a good reason for considering use of the extended/combo bolus feature?
A. Cheese and Pepperoni pizza
B. Cheese enchilada plate
C. Pasta al dente
D. Salad bar
E. Baked potato
0.75 U/hr
Combination bolus
2 hours
4 Units
6 Units
B A S A L
Ideal for patients with gastroparesis (delayed stomach emptying)
Also, excellent for foods high in fat and protein (pizza, mexican food, pastas)
timetime
time
0.75 U/hr
The “Sleep bolus”
B A S A L I N S U L I N
. . ..
.
.
..
.
..
6 hours
time
180 mg/dl
80 mg/dl
Bedtime (10PM) BG: 251 mg/dl
Fasting (7AM) BG: 120mg/dl
5.5 units
glu
cose
bolus
A modified extended bolusFor treating a high bedtime BGCalculate correction doseDeliver it over 5-6 hoursReduces risk of low BG @ 3AM
6
time
1.00 U/hr
Effect of high GI food
B A S A L I N S U L I N
. . ..
..
.
..
.
..
2 hours
time
180 mg/dl
80 mg/dl
125 mg/dl
110mg/dl
Example: 1 to 10
60 grams high GI CHO
60 / 10 = 6
6
Blood sugar “spike”
glu
cose
bo
lus
CH
O
300 mg/dl
5-6 hours
Superbolusing: (i.e., Robbing Peter to pay Paul)
• Taking from basal to add to bolus insulin
• Useful for• high GI foods• large carb loads• faster correction of a
high BG
0.00 U/hr
9
time
1.00 U/hr
“Superbolus”
B A S A L I N S U L I N
. . ..
..
.
..
.
..
2 hours
time
180 mg/dl
80 mg/dl
125 mg/dl
Example: 1 to 10
60 grams high GI CHO
60 / 10 = 6 + 3 =
9
Normal BG change
glu
cose
bo
lus
CH
O
140 mg/dl
9
0.00 U/hr
Superbolus for faster correction
. . ..
..
.
..
.
..
2 hours
180 mg/dl
80 mg/dl
125 mg/dl
glu
cose
0.75 U/hr B A S A L
timetime
60 mg/dl
Exercise or other strenuous activity
Temp basal rates
.
0.95 U/hr
timetime
Alternate basal rate profile examples
W E E K D A Y B A S A L P R O F I L E 1
0.95 U/hr W E E K E N D B A S A L P R O F I L E 2
6 AM 11 AM
1.35 U/hr P R E M E N S T R UA L B A S A L P R O F I L E 3
Surgery and the Pump
If possible, wear the pump. It’s the best way to control blood sugar during the operation, especially for minor procedures (e.g., dental)
If infusion site is in the operating field, simply relocate the site the day before
The anesthesiologist can monitor blood sugar and adjust IV sugar as needed to keep sugar levels under control.
D5 0.45 NS
Peak activity
Duration
NPH (0.3 - 0.4 U/kg)
Aspart or lispro (0.1U/kg)
RULE: insulin action via a pump is short-lived. Rapid-acting injected insulin can serve as a “bridge” while longer acting insulin provides “basal” insulin coverage.
Basal rate
Option 1
2 hours
Duration
Glargine (~basal dose)
Aspart or lispro (0.1 U/kg)
RULE: insulin action via a pump is short-lived. Rapid-acting injected insulin can serve as a “bridge” while longer acting insulin provides “basal” insulin coverage.
Basal rate
Option 2
2 hours
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