Transcript Insulin Pumps: A Better “Shot”at Diabetes Care

Insulin Pumps:
A Better “Shot”at
Diabetes Care
The 32nd Annual School Health Conference
Thursday, May 20, 2010
Overview
• Epidemiology
• Pathogenesis
• Insulin Therapy
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Importance of Control
Insulin Types/ Delivery Systems
Pump Basics
Pump Brands
Infusion Sets
Pump Candidates
Starting on a Pump
• Hypoglycemia
• Hyperglycemia
• Case Scenarios
Type 1 Diabetes Mellitus
• Previously referred to as insulindependent or juvenile diabetes
• Polygenic, multifactorial, autoimmune
disease
• Most commonly occurs in the young
Epidemiology
• In 2004, 3 million Americans were
estimated to have type 1 diabetes.
• There is a 3% increase in incidence per
year.
• Approximately 1 in every 400-500 children
has type 1 Diabetes.
• Diabetes is second most common chronic
disease in childhood after asthma.
Epidemiology
• Peak ages at onset: 5-7 and early
puberty
• 30% of cases onset 18 - 40 years of age
• There is a genetic association in regards
to the risk of developing diabetes.
Risk for Type 1 Diabetes
By Family Member with Diabetes
Pathogenesis of T1DM
• T-cell mediated process directed at
pancreatic  cell.
• Pancreatic islet cell destruction results
in absence of insulin.
• Absence of insulin causes chronic
hyperglycemia.
Natural History of Type 1 Diabetes
Genetic Predisposition
Immunological Abnormalities
Normal
Impaired
insulin
insulin
release
release
Beta-cell
Mass (% max)
100
Overt
diabetes
50
“Honeymoon”
period
0
Birth
Time (years)
What does insulin do?
• Insulin is a hormone secreted by the
-cells of the pancreas in response
to rising glucose levels.
• Insulin is a “key” that allows
peripheral tissues to open and allow
glucose to enter.
What does insulin do?
Absence of Insulin
• Absence of insulin causes the body to act in
fasting state, despite being fed.
• Serum glucose cannot be used by peripheral
tissues because of dependence on insulin.
• Stimulation of hepatic glycogenolysis and
gluconeogenesis cause further hyperglycemia.
• All of the above cause serum glucose levels to
exceed the renal threshold (180 mg/dl) and
glucose is spilled into the urine.
Glycemic Control
in Type 1 Diabetes
Changes in Diabetes Management
The Effect of Intensive Treatment of Diabetes
on the Development and Progression
of Long Term Complications
in Insulin Dependent Diabetes Mellitus
The Diabetes Control and Complications Trial
Research Group
NEJM 1993 Sep 30;329(14):977-86.
Diabetes Control and
Complications Trial (DCCT)
10.0
9.5
9.0
8.5
Conventional
Intensive
Hemoglobin 8.0
A1c
7.5
7.0
6.5
6.0
Adults
Adolescents
Risks & Benefits of Intensive
Diabetes Therapy (DCCT)
• Decreased Risk
– Progressive retinopathy
– Microalbuminuria
– Neuropathy
(%)
60
40
60
• Increased Risk
– Severe hypoglycemia
(%)
300
Glycemic Control in Pediatrics
• Controversy remains about the level of glycemic
control that should be targeted for children despite
the findings of fewer complications with better
control.
• Concerns exists given the high risk of
hypoglycemia and what hypoglycemia can do to the
developing brain.
Glycemic Control in Pediatrics
• Consensus Statement from the American
Diabetes Association targets the following
goals:
Age
Pre-prandial Bedtime / overnight
(years) Blood glucose
Blood glucose
(mg/dl)
(mg/dL)
Hemoglobin
A1C (%)
<6
6-12
100 - 180
90 - 180
110 - 200
100 - 180
<8.5 (but >7.5)
<8
13-19
90 - 130
90 - 150
<7.5
Diabetes Care 2009; 32: S13-S62.
How is glycemic
control achieved?
Insulin Therapy
Action Profiles of Insulins
Aspart, glulisine, lispro 4–5 hours
Plasma
Regular 6–8 hours
insulin
NPH 12–16 hours
levels
Detemir ~14 hours
Ultralente 18–20 hours
Glargine ~24 hours
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Hours
Burge MR, Schade DS. Endocrinol Metab Clin North Am. 1997;26:575-598; Barlocco D. Curr Opin Invest
Drugs. 2003;4:1240-1244; Danne T et al. Diabetes Care. 2003;26:3087-3092
How can insulin be delivered?
•Draw up from vial and administer with
syringe
•Insulin pens
•Insulin pumps
Insulin via Syringe
• Insulin is drawn from a vial
into a 28-31 gauge insulin
syringe
• Used for all patients who
are newly diagnosed with
diabetes as insulin doses
are being adjusted daily
Insulin Pens
• Doses are “dialed up”
• Administer like insulin injection via syringe
and hold down back of pen
• Benefits: Faster than syringe injections
• Drawbacks: Less fine tuning of doses due
to increments and pre-mixed pens come in
specified dosages (70/30 or 75/25)
3 Injections a day
U/mL
100
Aspart, glulisine, or lispro
NPHB
NPH at bedtime
L
D
80
60
Normal pattern
40
20
0600 0800
1200
1800
Time of day
B=breakfast; L=lunch; D=dinner
2400
0600
3 injections a day
U/mL
Aspart, glulisine, or lispro
100
B
L
D
Levemir
80
60
NPH
40
Normal pattern
20
0600 0800
1200
1800
Time of day
B=breakfast; L=lunch; D=dinner
2400
0600
4 + Injections a day
U/mL
Aspart, glulisine, or lispro
100
B
L
D
80
Glargine or
Levemir
60
40
Normal pattern
20
0600 0800
1200
1800
Time of day
B=breakfast; L=lunch; D=dinner
2400
0600
First Outcome Study of
Pumps in Pediatrics
Reduction to normal of plasma
glucose in juvenile diabetes by
subcutaneous administration of
insulin with a portable infusion pump
WV Tamborlane, RS Sherwin,
M Genel, and P Felig
NEJM 1979; 300:573-8
The Development of
the Insulin Pump
Autosyringe AS2C
Used 50mL syringe
Had only one basal rate
No memory
Slightly noticeable
when worn
NEJM 1979; 300:573-8
Barriers to Pump Use Pre-DCCT
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SIZE
Technical Limitations of early pumps
Fear of hypoglycemia
Fear of weight gain
Psychosocial Issues
Lack of commitment to intensive therapy
• Patients
• Parents
• PHYSICIANS
Barriers to Pump Use Pre-DCCT
Many pediatric endocrinologists were
reluctant to use pumps to treat
patients with type 1 diabetes. A lack
of data about pump use in children
was often cited.
Therefore, studies
on the benefits of
pump therapy in
pediatric patients
were completed.
Changes in HbA1c Levels
8.5
p=.89
(NS)
8
p = .03
7.5
Pump
MDI
7
6.5
Baseline
4 wks
8 wks
12 wks
16 wks
Average Pre-Meal Glucose
Levels
230
P<0.001
210
MDI
190
CSII
170
150
130
110
90
Breakfast
Lunch
Dinner
Bedtime
Improved Control With CSII
8.5
DCCT
Adol
8
7.5
HbA1c
Pre
12 mos
Recent
7
6.5
6
5.5
< 7 years
7-11 years
12-18 years
Age
Ahern, et al. Pediatric Diabetes 2002
Reduced Risk of Severe
Hypoglycemia
DCCT
Adol
40
35
seizure
or coma
events per
100 pt yrs.
30
25
20
15
10
5
0
12 Months Pre-Pump
12 Months Pump Rx
Glycemic control Pre and post
pump therapy in children <7 years
Pediatrics 2004;114:1601-1605
Improvement on Pumps
Pediatric Diabetes 2006; 7 (Suppl 4) 15-19.
Change in Hemoglobin A1c
Pediatric Diabetes 2006; 7 (Suppl. 4): 20-24.
Advances to Pumps
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Smaller size (roughly the size of a pager)
Multiple basal rates
Temporary basal rates
Direct glucose entry from meter or continuous
monitor
Able to check history
Reminders and alerts
Ability to disconnect infusion sets
Bolus wizard availability
• Preprogrammed carbohydrate ratios and correction
factors
• Glucose targets
• Duration of insulin action
Pump Basics
Pump Basics
• External, programmable pump
• Continuously delivers insulin via indwelling
subcutaneous catheter
• Requires input from wearer
• About the size of a cell phone/pager
• Operates on a AAA battery
• Hold up to 300 units of insulin
Pump Basics: Insulin Delivery
• Uses only Rapid Acting insulin
(NovoLog®, Humalog®, Apidra®)
• Patient no longer uses long acting
insulin
• Insulin delivered in 2 ways
– Basal
– Bolus
Pump Basics: Basal Rates
• Continuous “background” level of insulin
• Basal rates are programmed in units/hr
• Pump breaks down hourly insulin
delivery rate into drips delivered every
few minutes
Pump Basics: Basal Rates
Background insulin released slowly
throughout the day.
Lantus or Levemir
Pump
2:00
7:00
12:00
16:00
20:00
24:00
7:00
Time
Basal insulin delivery from a pump provides
a better and faster match for life’s needs
Pump Basics: Temporary
Basal Rate
• Temporary adjustment to basal pattern
• Set in response to change in usual activity
– Exercise (lower the usual basal pattern)
– Sick Day (increase the usual basal pattern)
• Programmed by
– Duration
– % of Basal
– Example: Temporary rate at 200% for 3 hrs
• Pump automatically returns to usual basal
pattern at completion of temporary rate
Pump Basics: Bolus Insulin
• “Burst” of insulin programmed at the
time it needs to be delivered.
• 2 Types of Boluses
– Correction Bolus
– Meal Bolus
Correction Bolus
• Dose of insulin given to “fix” a BG that is
outside of target range
• Dose is based on:
– Correction Factor (pre-programmed in the
pump)
– Target BG (pre-programmed in the pump)
– Actual BG (entered into the pump by the user)
• Corrections should not be given more
frequently than every 2 hours
– Giving corrections more frequently risks
“stacking” the corrections
– “Stacking” causes low BG levels 4-6 hours later
How to Calculate a
Correction Dose
1. Need: Correction Factor, Target BG, and Actual BG
2. Subtract Target BG from Actual BG
3. Divide Answer from # 2(above) by Correction Factor
Example: Correction Factor – 1 unit per 125 mg/dL
Target BG – 100 mg/dL
Actual BG – 295 mg/dL
295-100 = 195/125 = 1.6units
Meal Bolus
• Dose of insulin given to “cover” the carbs in
a meal
• Dose is based on
– Total grams of carbohydrates in meal
– Insulin to Carbohydrate ratio (I/C)
• Designed to bring BG back to where it
started
– Pre-meal BG is 235 mg/dL
– 2hr PP BG will be around 235mg/dL
• Bolus must be given before meal to limit
after meal increase in BG levels
How to Calculate a
Meal Bolus
1. Need: insulin to carb ratio, total # carbs in
the meal
2. Divide total # Carbs by Insulin to carb ratio
Example:
Total # carbs = 95 grams
I/C – 1 unit per 12 grams
95/12 = 7.9 units
Carbohydrate Counting
• Allows for more flexibility
• Only grams of
carbohydrate are
counted
• Insulin dose is varied
based on amount of carb
and blood sugar level
• However, it is important
to note serving size!
What About Sugar?
•Carbohydrates are carbohydrates no matter what
the source of the carb is.
•Table sugar, sweets, and candy will be broken
down into glucose.
•As long as someone with diabetes counts the
carbohydrate they are eating or follows a prespecified amount of carbohydrates daily, it is okay to
eat such foods.
How Fat Affects Your Blood
Glucose Level
• Fat takes longer to empty from the stomach
which delays the absorption of glucose into
the bloodstream
• This process can cause the glucose to rise in
4-6 hours, when the carbs are being
absorbed, but there is not adequate insulin
circulating to cover the carbs at that time
• Glucose can stay high for quite some time
after a high fat meal
Advanced Bolusing
Normal Bolus
Normal bolus
Whole bolus delivered now
Basal
Square Wave Bolus
Square Wave Bolus
Bolus delivered over time duration
Dual Wave (normal + square)
Percentage of bolus now and percentage over time
duration
Dual Wave Bolus
Types of Bolus:
Square Wave or Extended
• Delivered gradually and evenly over an extended
period of time
• The peak is delayed and blunted, and the
duration of action is lengthened
• Delivery can range from 30 minutes to 8 hours
Square Wave Delivery
Square Wave Action
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1
2
3
4
5
Types of Bolus:
Dual Wave or Combination
• A portion is delivered immediately (normal bolus)
and another portion is delivered gradually
(square wave bolus)
• The initial 1-hour peak occurs but is diminished
• There is a second delayed/blunted peak and a
longer duration of action
Dual Wave Delivery
Dual Wave Action
0
1
2
3
4
5
Why Use Square
Wave/Extended or Dual
Wave/Combination Boluses?
• With slowly digesting foods, normal boluses may
peak too soon and stop working too soon
• This can cause a glucose drop soon after eating,
and a glucose rise several hours later
Delivery
Action
0
1
2
3
4
5
Basals And Boluses
Bolus
bolus
basal
Suspend pump
for exercise
Basal Rate
A pump more easily matches the realities
of daily life.
Insulin Pump Brands
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Accu-check Spirit
One Touch Ping by Animas
Deltec CozMore 1800
Insulet Omnipod
Medtronic Revel x23
Accu- Check Spirit
•Bolus based on BG
•Holds 315 units
•0.1 unit basal rates & bolus increments
•Reversible display
•Side mounted tactile buttons
•Accu-Check Pump Configuration Software
•IR (direct line) control from optional Palm PDA or smart
phone
•Database of 1,000 Calorie King foods in PDA
One Touch Ping by Animas
•Bolus can be delivered from One Touch meter up to 10
feet away
•High contrast color screen for easy viewing
• Smallest mainstream pump
•Basal rate increment 0.025 u
• Waterproof – 12 ft for 24 hrs
• ezCarb meal bolus calculator
•ezCarb stores 500 foods
• ezBG correction bolus calculator
• ezBolus shortcut to give bolus
Deltec CozMore 1800
•Most features: HypoManager, Weekly Schedule, Missed
Meal Bolus, Disconnect Bolus, Basal Test, Meal Maker
with CozFoods, Therapy Effectiveness
• Most flexible setup
DISCONTINUED!!!
• Direct BG entry from attachable Freestyle meter
• 300 units
• 0.05 unit basal and bolus increments
• Accurate bolus calculations
• IR download
• Best for blind or visually impaired
Insulet Omnipod
•No tubing for easy wear
• Automatic cannula insertion and priming
• 200 units
• Limited to 72-80 hrs use
• Watertight
• Controlled by PDM or smartphone
• 1000 food database
Medtronic Revel
•Simple interface, less scrolling
•Proprietary infusion sets
• One Touch meter transmits BG directly
•Bolus wizard (calculator for bolus doses)
•Basal increments 0.025 units/hr
•CareLink online software
•CGM displays BG, 3 hr trend, trend arrow, and advance
warning of lows and highs
• Considered least accurate CGM for detection of lows
Infusion Sets
• Inserted under the skin in subcutaneous
tissue.
• Cannulas can be 6mm-17mm in length.
• Can use Emla Cream prior to insertion.
• Changed every 2-3 days.
• Placed in abdomen or buttocks.
Infusion Sets
• Five varieties:
o
o
o
o
o
Self-contained (Omnipod)
Slanted Teflon
Straight-in Teflon
Slanted metal
Straight-in metal
• Three connections:
o Luer lock pumps: ~ 25 varieties
o Paradigm: ~ 4 varieties
o Omnipod: 1, auto-inserted
Infusion Sets
• Tubing may be disconnected without
removing insertion site
– Should be removed for swimming or bathing
– Should be removed for contact sports
– May be removed for other sports
– If disconnecting for more than 2 hours, patients
should check their blood sugars, reconnect, and
give a bolus to prevent hyperglycemia
How are the pumps
worn?
• Older patients will wear the pump on a
clip which can be attached to a belt,
pants, or in a pocket.
• Pumps can also be left without a clip
inside a pocket.
• Special pump holders are sold which can
be attached to the thigh or inside of bra
to hold pump for discretion.
• Younger patients may use pump packs.
“Bad” Infusion Sets
• Infusion set may go “bad” (pulled out, kinked, or
blocked).
• Because the pump only uses rapid-acting insulin if
the site is not changed may end up with
hyperglycemia or Diabetic Ketoacidosis.
• So, if someone on a pump has a high blood sugar:
1- A correction is given through the pump.
2- Re-test blood sugar in 2 hours. If still high, then
change infusion set and give injection of insulin.
3- Check urine for ketones.
Who is a Pump Candidate?
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Hemoglobin A1C of <8%.
Testing blood glucose 4 times a day.
Logs blood glucose.
Counts carbs.
Comes to clinic for follow up. Knows
how to contact diabetes team.
• Realistic expectations.
Expectations
Unrealistic
Realistic
The pump will cure my diabetes.
I will feel better.
I won’t have to test as much.
I must test at least 4 times a day.
I won’t have to log my blood
sugar.
I will have to log my blood sugar
to adjust my pump settings.
I can eat anything I want.
I will have more freedom with my
food choices if I bolus for my carb
intake.
My blood sugar will be perfect.
I will have better control with fewer
lows.
It will be as very easy to start a
pump.
It will take time to learn and adjust
to the pump.
Starting on a Pump
• Not started at diagnosis because:
• Family needs time to cope with diagnosis.
• Initial period of insulin resistance followed by
possible honeymoon period. Meaning doses are
undergoing daily changes at first.
• If pump breaks, need to take shots. So,
everyone needs to be proficient in taking shots.
• Insurance issues.
Starting on a Pump
• Patient chooses pump and insurance
coverage is sought.
• Pump is shipped to family.
• Family educates themselves in regards
to pump via DVDs from pump
companies, online tutorials, information
packets.
• Pump company sends trainer to home to
initiate pump therapy. Baseline settings
for pump sent by our group.
Starting on a Pump
• Blood glucose tested
o Premeal (breakfast, lunch, dinner, bedtime
snack)
o 2 hour post meal (to assess carb ratio)
o 12 a.m. and 3 a.m. (to assess basal rates
• Family calls daily for~2 weeks for
adjustments to pump settings.
Pump Therapy
• Patients are advised if blood sugar
<70mg/dl to take fast acting sugar (4oz of
juice, glucose tablets, candy).
• If blood sugars are >300 twice or if >300
when waking up, insertion set must be
changed.
• Given only short acting insulin used, if
tubing kinked or other problems risk of
Diabetic Ketoacidosis if site is not
changed.
Pump Therapy
• Then, patients are seen every 3 months
for follow up in clinic.
• Dose adjustments are made daily
between 1-4p.m. for any patient who
needs them.
• 24 hour emergency line is available.
The highs and lows
of diabetes:
Hypo and
Hyperglycemia
Causes of Hypoglycemia
• Too much insulin
• Inadequate food intake
• Delayed meals or snacks
• Exercise
Symptoms of Hypoglycemia
Moderate/Severe Hypoglycemia
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Lethargy
Extreme weakness
Unsteady Gait
Combativeness
Seizure Activity
Unresponsiveness
Treatment of Mild Hypoglycemia
• Child is responsive and able to swallow
• Blood sugar is <70mg/dL
• Give 15 grams of FAST ACTING
carbohydrate
(3-4 ounces of juice, 3 glucose tablets)
• Re-test in 15 minutes if persistence of
symptoms see if blood sugar has risen.
Treatment of Mild Hypoglycemia
• Children who are able, can keep this
treatment in the classroom.
• Children should be assisted to the nurses
office if necessary.
• Children on insulin pumps may need less
glucose for treatment.
Over treatment of Hypoglycemia
• More is not always better!!!
• Over treatment of lows can cause
hyperglycemia in the next 1-3 hours
• If patterns of lows persist over days, family
should be notified so insulin adjustments
can be made.
Treatment of Moderate/ Severe
Hypoglycemia
• Defined as requiring assistance of an adult to get
treatment.
• If child is able to sit and swallow, use juice or glucose
tablets
• If unable to swallow, use glucose gel first squirting the
tube on the buccal mucosa.
• If gel isn’t bringing the glucose up, then use call 911
and/or use glucagon.
Glucagon
• If altered level of consciousness or
seizure activity consider glucagon use.
• Mix powdered glucagon with diluent.
• Draw mixture up in insulin syringe.
• Administer subcutaneously.
Prevention of Hypoglycemia
• Child may need juice or glucose tabs
before gym class or recess
• If necessary, the pump may be
disconnected for gym class or recess.
• If recurrent lows inform the parents so
they can call their clinicians to make
dose adjustments.
Causes of Hyperglycemia
• Inadequate doses of insulin
• Additional carbohydrates
• Missed injection of insulin – glucose will be
very high with ketones
• Malfunctioning pump catheter – glucose will
not respond to corrections given via pump,
ketones may be present
• Illness – ketones may be present
• Lipohypertrophy – scar tissue at injection
site
Symptoms of Hyperglycemia
Signs/Symptoms of
Hyperglycemia and Ketonuria
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Extreme thirst
Increased urination
Abdominal pain
Nausea/vomiting
Weakness
Dizziness
Labored breathing
Hyperglycemia Correction
• Correction can take 2-3 hours to normalize glucose
• If glucose is not decreasing after 2 hours in a child
on pump, then an insulin injection should be given
• If the child feels okay he/she may
• Return to class
• Participate in gym
• Sugar free liquids help with hydration
• Contact Yale if treatment plan requires clarification
(203) 764-6747.
Hyperglycemia Correction
Most patients will have personalized correction
factors but the guidelines below can be helpful
to determine a correction factor based on age.
Age (years)
Correction Factor (mg/dL)
<3
225
4-5
200
5-7
150
8-11
125
Prepubertal and/or
<13
Pubertal and/or >13
75
50
Treatment of Hyperglycemia
with Ketonuria
• Parents should be contacted immediately
• Parents call Yale Pediatric Diabetes Clinic at
(203) 764-6747
• Increased amounts of insulin will be required
via injection.
• Provide sugar free liquids.
• Insulin is required even with vomiting and
hypoglycemia with ketones.
• No exercise with ketones
Scenarios
Scenario # 1
A student on a pump performs a
routinely scheduled BG test just before
lunch and the result is 61 mg/dL. The
student is asymptomatic.
What is the most appropriate action to
take?
Answer to #1
• Treat the low with 15grams fast-acting carbs
• Send the child to lunch if feeling okay.
• For children on pumps: consider bolusing ½
before heading to lunch and the other ½
after lunch
Scenario # 2
13 yo student on a pump. Pre-lunch blood
glucose is 302 mg/dL. The student
boluses for both meal coverage and a
correction. You ask the student to come
back 2 hours later for a BG check. At that
time, the BG is 290 mg/dL.
What is going on?
Answer to # 2
Most likely the pump site is no longer working.
What actions should be taken?
– Urine should be checked for ketones
• If ketones are present, parent should be notified
immediately
– Student should (if able) change site and administer
correction dose either via pump or via injection
– If unable to change site, administer correction dose via
injection and contact parent
– If child feels well and no ketones present, may return to
class (if unwell or ketones present, contact parent)
– Repeat BG in 2hrs
Scenario #3
A 6yo student is normally quiet and
follows directions well. One afternoon
during quiet reading time he starts to
read out loud and states he is tired and
puts his head down on the desk.
What is most likely going on?
Answer to # 3
Hypoglycemia
Student may not have recognized earlier signs and
symptoms of hypoglycemia and now we are seeing some
neurological signs and symptoms
Any sudden change in behavior is
most likely due to hypoglycemia
What actions should the teacher take?
Answer to #3
• The teacher should have the child test his
blood in the classroom and treat if his blood
sugar is <70mg/dL.
• If the child is unable to test in the
classroom, he should be accompanied
down to the nurse’s office to have his blood
sugar checked.
• If blood sugar <70mg/dL and the child is
unable to swallow, consider using glucose
gel or glucagon.
Scenario # 4
A 9yo student has had BG levels >
250mg/dl for at least 3-4 days per week
for the last 2-3 weeks before lunch.
You have been giving correction doses
of insulin each day at lunch.
What is the best course of action for
managing this patient’s BG levels?
Answer to # 4
• Any recognizable patterns in BG levels
require adjustment of insulin doses
• Parent should be advised to contact the
Yale Pediatric Diabetes Clinic for dose
adjustments at (203) 764-6747.
• In this case, either the basal rates may
need to be changed or the breakfast carb
ratio may need to be changed.
• Some parents feel they need to wait for a
visit for a dose adjustment – that is not the
case especially w/ pediatric patients
Scenario # 5
A 12yo student come into your office shortly after
arriving at school and states she is not feeling well.
She indicates that she did not eat much this morning
because her stomach hurts and “everyone” at home
has the stomach bug. She proceeds to vomit in the
office
What is/are the first steps to take?
Answer to #5
• Check the BG (98 mg/dl)
• Check for Ketones (moderate-large)
• Contact the parent
– This child needs to be monitored closely at
home and the parent should contact our office
right away
– Additional insulin needs to be given to reduce
the ketones but fluids/foods with glucose need
to be given at the same time
Emergencies we want to know about right away:
Vomiting, persistent hyperglycemia, moderatelarge ketones, severe hypoglycemia
Scenario # 6
One of the 6th grade teachers calls you at the
beginning of the school day to let you know
that a mother is bringing in cupcakes for the
class. They will be having the cupcakes
whenever the mother arrives. The teacher is
concerned about the 11yo boy in her class
who has diabetes. She called to ask your
opinion about what to do.
What is the best course of action?
Answer to # 6
•
Contact the parent to confirm that the student is okay to
have a cupcake
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–
•
Developmentally, this child does not want to be singled out
Also important to learn that diabetes does not limit a child’s
participation in school activities, it requires additional
actions/safeguards
Going forward
–
–
–
Teacher should notify you of any special events – well before
they occur so that you may work w/ parent to accommodate the
events
Try to determine carbs of food to be eaten
Grams of carbs should be estimated and entered into the pump.
Yale Pediatric Diabetes
William Tamborlane, MD
Stuart Weinzimer, MD
Eda Cengiz, MD
Kristin Sikes, APRN
Patricia Gatacomb, APRN
Andrea Urban, APRN
Kerry Stephenson, ARPN
Kate Weymen, APRN
Heather Mokotoff, APRN
Pauline Rose, CDE
Sylvia Lavietes, LCSW
Jodie Ambrosino, PhD
Jennifer Sherr, MD
Ania Jastreboff, MD
Anisha Patel, MD
Michelle Vanstone, MD
Valeria Benavides, MD
Grace Kim, MD
Amy Steffen
Lori Carria
Melody Martin
Karen Esposito
People
with
diabetes
are NOT
diabetic.
They are
living with
diabetes.
Thank you
Questions????