Transcript PowerPoint Presentation - Starting on an Insulin Pump

Continuous subcutaneous
insulin infusion therapy
(CSII)
Karen Palmer
Credentialled Diabetes Educator
Melbourne Health
CSII therapy
• CSII therapy is becoming increasingly popular with
people who have type 1 diabetes world wide
• Over 7000 pumps in use in Australia
• Today's pumps are small, high tech electronic
devices which can make life with diabetes more
flexible
Management of pump in hospital
•Contact DE office hours
•If patient is well and able to
look after the pump – leave it
in place
•If unable to self manage or
no peri operative plan – switch
to MDI’s/insulin
•Refer to endocrine registrar
Indications and suitability for CSII
• Poor glycaemic control
• hypoglycaemia
• hypo unawareness
• Frequent hospitalization/DKA
• Dawn phenomenon
• gastroparesis, pregnancy
• Insulin resistance -Type 2 diabetes
• Flexible Lifestyle
Potential advantages
• A more predictable/consistent absorption of insulin
• Improved glycaemic control/less risk of complications
• Less hypoglyaemic events
• Greater flexibility in meal timing
• Easier/faster adjustments of insulin for sickness and
exercise
• Easier handling of travelling through time zones
CSII therapy
• It is important that you have realistic
expectations about pump therapy.
• It is not a cure for type 1 diabetes but a way of
delivering insulin that may offer increased:
• flexibility
• improved glucose control
• improved quality of life.
Expectations
Unrealistic
Realistic
The pump will cure my diabetes
I will feel better
I won’t have to test as much
I must monitor very frequently
I can eat anything I want
I will have more freedom with
my food choices
My blood sugar will be perfect
I will have better control with
fewer lows
It will be as easy to learn as a
meter
It will take time to learn and
adjust to the pump
CSII therapy
• Pump therapy requires:
• motivation
• regular blood glucose testing
• the ability to learn pump technology
• Regular follow up by the diabetes team
RMH pump process
• Referral from endocrinologist
• Pre pump group
• Pre reading
• Pump clinic for assessment
• Dietitian for CHO counting
• Pump start
Where pumps began…
The first insulin pumps appeared in 1978
Used large 50 ml syringe that required users
to dilute insulin
Had only one basal rate and no memory
Smart Pumps
Animas R1200
Medtronic Real time
Roche Spirit Combo
How do pumps work?
• An insulin pump is a small electronic device about the size
pager small mobile phone.
• Insulin is delivered from the reservoir/cartridge through
flexible tubing fitted with a small Teflon® (or steel) cannula
which is inserted subcutaneously
• delivers insulin in two ways: Basal rate and bolus dose
How do pumps work?
• Basal-deliver very small amounts of insulin continuously
0.025units/hr
(replaces the need for long acting insulin)
• Bolus- delivering a dose of insulin on demand to account
for the carbohydrates in meals or to correct high BGLs.
Basals And Boluses
bolus
basal
Basal Rate-
(background insulin) Continuous flow of rapid-acting insulin. If correctly
set, the blood sugar remains within normal limits
Bolus Dose-
delivering a dose of insulin on demand to account for the carbohydrates in
meals or to correct high BGLs.
Calculating rates and ratios
• 50% Basal
• 50% meal bolus doses
Calculation of Starting Doses
Based on pre-pump total daily dose (TDD)
• Pre-pump TDD = 70 units
• Reduce by 28%
• Pump starting dose = 50
• Basal = 25units = 1unit/hr
units
How many basals
Most pump users will eventually have a
sculptured basal pattern consisting of 3-6
basal rates/24hr
Insulin/CHO ratio
How many grams of CHO are covered by 1 unit of insulin
Establish insulin/CHO ratio using
‘500 rule’
500/TDD
Eg TDD - 50units
500/50 = 10gms/1unit insulin
Bolus Types
Boluses can be delivered in one of three ways to
accommodate various situations
• Normal-
all at once
• Square wave-
gradually over time
• Dual Wave-
a portion immediately followed by
remainder over time
Correction Factor
How many mmol one unit of insulin will lower the BGL
‘100 rule’
100/TDD
Eg TDD - 50units
100/50 = 2 mmol drop/1unit insulin
Smart pump Calculator
Edit Settings
Wizard:
on
Carb units:
grams
Carb Ratios:
15
BG Units:
mmol
Sensitivity:
2.8
BG Target:
5.6– 5.6
Active Insulin Time:
6 hrs.
When to use Temporary Basal Rates
Hypoglycaemia
Exercise (inc housework)
Sick days
Menstruation
Lazy days
Disadvantages
Potential disadvantages
• Being permanently attached to a ’machine’
• More blood glucose testing
• More rapid development of ketones or
Ketoacidosis
• Skin infections or irritation
• Weight gain
Potential causes of unexpected
hyperglycemia/DKA
•Leaks
O-rings
Hub
Line
•Clogged lines
•Site infections
•Allergies
•Bleeding under skin
•Hypertrophy
•Insulin :
Cloudy
Beyond expiration date
Exposed to extreme
temperatures
Prevention of Skin Infections
• ‘Clean’ technique
• Always clean area prior to inserting cannula
• Do not leave cannula in situ longer than recommended
• Examine infusion site daily
High BG Checklist
• Check for leaks or smell insulin?
• Infusion set in place?
• Are connections at hub and O-rings tight?
• Obstruction
• Redness/inflammation
• Air in the tubing? (2.5cm = 0.5unit)
DKA Prevention Guidelines
•
Prompt and appropriate action should be taken in the event of
hyperglycemia:
•
Monitor BGLs frequently
•
Refer to hospital management guidelines
•
Detect problem
•
May use temporary basal rate to increase basal delivery
Summary
• High degree of motivation
• Willing to monitor/record BGLs
• An ability to interpret BGLs
• Willing /ability to quantify CHO
• Willing to comply with medical follow-up/post training
• Realistic expectations - a pump is a tool not a cure
• CSII are not for everybody
Summary
• Management of patient in hospital
– If patient is able to manage, leave pump in place
– If unable to manage- switch to MDI/insulin infusion
– Refer to Endocrine registrar
– Refer to DE