Transcript Insulin Pump Basics

INSULIN INFUSION PUMP
Seminar by;
Vemula Praveen Kumar
M.pharmacy II semester
(Pharmaceutics)
University College of Pharmaceutical Sciences,
Kakatiya University,
Warangal.
CONTENTS
 Introduction to insulin infusion pumps (pump)
 How to choose a pump and infusion set
 Working of pump
 Use of pump
 Formulas that help
 Site & site supplies
 Advantages &disadvantages with pumps
 Problems with pump & site
 Helpful habits & attributes
 Conclusion
 References
About insulin
Insulin is a hormone, normally produced by pancreas
Low levels of insulin (basal insulin) are required to
block the uncontrolled breakdown of fats and glycogen
into energy substrates for the body
High levels of insulin(bolus insulin) stimulate the
storage of sugar in muscle and fat.
Insulin Infusion Pump
 Insulin infusion Pump (IIP) is an
external battery-powered device that
delivers insulin at regularly
scheduled intervals, day and night
(through a short, flexible plastic tube
inserted just under the skin), into the
body at a programmed rate to
control blood sugars
Insulin release pattern
R/Lispro/Aspart
Endogenous insulin
Insulin Effect
Three Injection Regimen
Ultralente
B
L
D
Insulin release pattern
Endogenous insulin
Insulin Effect
CSII or IIP
B
L
D
Continuous delivery through the IIP, more closely
mimics the natural secretion of insulin from the pancreas.
Insulin Infusion Pumps
Fairly recent technology.
Generally fairly easy to use.
Requires close patient involvement.
More thinking and monitoring than insulin by
syringe.
3,00,000 users worldwide.
Operation is very simple, because the interface
is similar to a cell phone keypad.
Where Pumps Began
 Started ~1978 with conversion of
portable chemotherapy pumps to
delivery of insulin
 The Auto syringe AS2C and Harvard
Apparatus Mill Hill Infuser were first
 Single basal, no memory
 50 ml syringe on pump exterior
1978 Autosyringe AS2C –>
1977Blood
Glucose Meter
Block Diagram of IIP
When To Consider A Pump
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More than 3 injections per day
Tired of multiple injections
Frequent or severe hypoglycemia
Hypoglycemia unawareness
DKA hospital admission
Require small, precise doses
Less risk of complications
Terms
# Basal Rate: that which is flowing between meals or
boluses
# Bolus: sudden increase such as to adjust for a meal
or abnormal sugar
# Suspend: to stop the basal rate for some time
# Infusion set: the cannula and tubing that goes from
pump to skin and SQ tissue
Types of Pump
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Open loop: User gathers sugar data and adjusts
flow rates for activity, diet, other changes in
sugar
Closed loop: The device checks sugar and
adjusts insulin infusion
Pumps use short acting insulin
Disappears faster
Acts faster, so adjustments made faster
First Steps Toward A Pump
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Keep detailed records
Consider your (and your child’s) motivation
Acceptance issues, family support
Look at available pumps
 Which pump(s) does your insurance cover?
 How your pump works
 When to increase and decrease basals and
boluses
 How to adjust for high GI foods, extra activity
Things To Consider while selecting a
pump
Look, feel, color
Features: reminders, child
block, waterproofing
Size of basal and bolus
increments
Infusion set choices
Safety
Customer support
History
Ease of data analysis
Add-ons: meters, covers
Pump Companies
 Animas R1200
 Dana Diabecare III
 Deltec Cozmo
 Medtronic Paradigm
 Nipro Amigo
 Roche/Disetronic
Working of IIP
 The pump is programmed to deliver a constant
background rate of insulin called a basal rate, which may
change at various times during the day, to closely match
the individual’s needs.
 Typically, the basal rate does not need to be changed
often, once the person’s blood glucose patterns are known.
 There may be some variation due to changing sleep / wake
schedules or monthly hormonal changes.
 These changes can be accommodated quite easily with the
pump and therefore achieve better blood sugar control
than insulin injections
Working of IIP
 A lead screw and nut (describes as a “drive rod”) that would
compress the syringe to inject the insulin.
 The lead screw pushes down on the drive rod, which is
actually a complex machined plastic plunger.
 The precision fit of the lead screw and nut not only ensures
the proper performance of the pump, it creates sealing
features that help maintain a strict separation between the
medication and the pump parts.
Before IIP Using
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Everyone is nervous
Read, read, read
Pumping Insulin, Kids Insulin Pumps
And You (Animas), and information
booklets, visit websites
www.myomnipod.com
www.minimed.com etc, etc ...
Do lots of recording before and after
start
Start to play with pump as soon as it
arrives
Get telephone contacts: MD, CDE, pump
company, pump rep.
IIP sites & Site Preparation
Prevents pump bumps, infection, and
abscess
Steps
Wash the hands
Sterilize the skin – IV Prep
Use bio-occlusive adhesive – IV 3000
Insert the set
Use safety tape
IIP sites
Site Supplies
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Emla cream (Rx, 30 min wait) or ice cube
Set inserter: ezSerter, Quick-Serter, Sil-Serter, Sof-Serter
Adhesive: IV-3000, Hypafix, Tegaderm
Tape: Micropore, Durapore, Band-Aid Blister Relief (wicking)
Sweating aid: Mastisol Spray (Detachol for removal), Skin Tac,
Tincture of Benzoin, Skin Prep
Adhesive removal: Uni-Solve, Allkare
Use of IIP
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The tube and needle are referred to as an “infusion set.”
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Infusion sets
Straight-In Teflon: Cleo, Inset, Ultra flex, Quik-Set
Easier to insert at variety of depths (6, 8, 9 mm)
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Angled Teflon (Comfort, Tender, Easy):
 Longer is more secure
 Adjust angle to reach fat
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Metal needles (Rapid-D or bent needle)
 As comfortable and often more reliable
 Very short, multi-needle infusion sets expected soon
Infusion Sets And Inserters
Smith’s Medical Cleo
Animas Inset
Quik-serter
Disetronic Rapid-D
Crab counting
 Carbohydrate counting is an effective way to control
insulin regimens by means of giving only enough
insulin to cover the grams of carbohydrate ingested.
With an insulin pump, you simply add up your
carbohydrates ingested, and insert the number into
the pump—just like a calculator.
 The pump then figures out, based on your
programmed ratio, how much insulin is needed to
cover your carbohydrates
 Allows precise matching of carbs with boluses
 Glycemic index, saturated fat, and high protein all
play a role, but grams of carb is what controls the
blood sugar after a meal
 Easy!
Carb Counting
 How To Count Carbs
 Food labels
Check portion size
 Books
Dr’s Pocket Guide, Health Cheques
 Keeps blood sugar normal after meals
 The formula for calculating a correction dose is as follows:
 1. Add the total daily dose (include both basal and bolus amounts) and
then divide 1,800 by that number. The result is the decrease in glucose
(mg/dl) one would achieve with 1 unit of insulin as a correction dose.
 1,800/Total Insulin Dose = Decrease in Glucose (mg/dl) per 1 unit of
insulin (This is the “insulin sensitivity factor.”)
 2. Calculate the number of units of insulin needed based on the current
glucose level and planned carbohydrate intake. Patients should test their
glucose levels 2–3 hours after delivering the bolus to assess the
outcome.
 Example: J.D. normally takes 30 units of insulin per day: 15 units as
basal and
 15 units as bolus (5 units with each meal)
 1,800/30 = 60 (insulin sensitivity factor)
 A correction dose of 1 unit of insulin would be expected to
decrease the blood glucose by 60 mg/dl. Patients should be
taught to use their insulin sensitivity factor (this can be
modified to ± 25%), as follows:
 Blood Glucose – Target/Sensitivity = Correction Dose
 If the premeal glucose is 198 mg/dl (~ 90 mg/dl above the
premeal target of 110 mg/dl), the patient would need to add
1.5 units of insulin to the bolus insulin dose.
 (198 – 110)/60 = 1.5 units
 J.D. would then add 1.5 units to his meal bolus dose to lower
his glucose into his target range.
 It is important to note that this is just a starting point that
must be assessed with follow-up blood glucose readings
after the correction bolus is given
500 Rule To Find Carb Factor
Gives grams of carb covered by one unit
of Humalog or Novolog
500 Rule provides a close estimate of carb factor if
the TDD is accurate
500 / TDD = grams of carb per unit of
insulin
Example:
 Person’s TDD = 50 units
 500/50 = 10 grams of carb covered by 1
unit of Humalog or Novolog
Post meal readings stay normal!
1 gram of carb
raises the BG
4 to 7 points!
2000 Rule To Find Correction Factor
 Gives how far your blood glucose is likely to fall per unit of insulin
over 5 hours
 2000 / TDD = # mg/dl your BG will fall per unit
 Example
Person’s TDD = 25 units
2000/25 = an 80 mg/dl drop per unit of H or Nov
 1600, 1800, 2000, or 2200 may be divided by TDD to get point drop
per unit
•
1800 provides a good average -
• 1600 Rule is more aggressive and
gives more insulin,
• while a 2000 or 2200 Rule gives
less insulin
Total Daily Dose
20 units
25 units
30 units
35 units
40 units
50 units
60 units
75 units
Point drop per unit
90 pts
72 pts
60 pts
51 pts
45 pts
36 pts
30 pts
24 pts
New Devices
 Data storage and download
 Easy recording of BGs, insulin, carbs
 Automatic carb counting
 Pattern recognition
 Insulin dose guidance
 Data analysis to improve control
 Feedback that encourages use
Pump — Meter Combos
CozMonitor from Deltec and
Therasense
Disetronic and Roche
Medtronic 512 and BD Paradigm
Link
Animas and Life scan
Dana Diabecare III and Dana meter
Sensor-augmented pump consisting of a Guardian RT sensor (A), which
is attached to a Minilink transmitter (B) and they communicate with an
insulin infusion pump (C).
The Big Three
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Medtronic Minimed
Paradigm 508, 512 / 515*, 712 / 715*
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Animas Corp.
IR1000, IR1200*, IR1250*
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Smiths Medical
Deltec Cosmo*
“Smart” Pumps
 Insulin pump software will calculate
mealtime insulin (bolus) based on:
 Current blood glucose
 Carbohydrate content of the meal
 Previous bolus (time and size)
*smart pump technology
Advantages
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Precise doses, as small as 0.025 u, can be given
Reminders
Little risk of infection
A freer lifestyle
Easier dose determinations
Improved blood sugars
Flexibility in meal timing and size
Ability to exercise without losing control
Peace of mind
Family activities are no longer tied to one
person’s needs
Easier handling of illness, travel, or camping
Insulin Infusion Pumps and Exercise:
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Normalize the glycemic and metabolic responses because insulin levels
can be easily increased, decreased, or maintained at basal levels.
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In anticipation of exercise, insulin bolus can be adjusted.
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Self Blood Glucose Monitoring (SBGM) - important and helpful.
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Disadvantages of IIP
10-15 minute delay in onset of insulin action
► Infusion site needs changing for every 3-4 days
► Always wearing a device
► Size of the infusion pump
► Vulnerability to trauma or disruption at the
infusion site
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Must be removed for water sports
Most Pump Problems Occur In
First
 First
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week
month
First 6 months
Problems are most likely when
unexpected or inconvenient
Occasional Pump Problems
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Setup tips
Leaks
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O-rings
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Hub
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Line
Clogs
Site infections
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Allergies
Bleeding
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onto skin
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inside needle
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under skin
Pump bumps
Dislodged infusion set
Some frustration at times is normal!
Will Your Pump Alarm?
Low battery
Mechanical problem
Empty reservoir
Clog
Forgotten bolus
Yes
Yes
Yes
Yes
Yes
Leak
Bleeding
Bad programming
Dislodged infusion set
No
No
No
No
Pumps don’t detect:
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Disconnection
Air in line
Infection
Leaks
Abnormal tissue sites
Infusion Site Problems:
Tissue abnormality
 Redness / pain / heat
 Hard tissue / scarring
 Kinked cannula
 Old site
 Improper depth / too near muscle / wrong angle
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Air in line
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Tube disconnected
Problems with Infusion Pumps
Out of insulin?
Is the pump leaking?
Is the connection between the tubing and the pump
cartridge tight?
Is the hub connection cracked?
Can you smell insulin anywhere? (hint: Insulin smells
like Band Aids)
Do the pump motor arms (MiniMed) or piston rod
(Disetronic) move freely?
Stocking of IIP
 Extra stock:
 Keep refrigerated (36° - 46°F). Discard after
expiration
 Current bottle in use:
 can be used for ~30 days at room temp
 (59°- 68°F optimally, below 86°F)
Helpful Attitudes And Habits
Be blatant about your diabetes
A pump is a tool, not a cure
Take a bolus for every bite
Change site as directed
Look for a solution for every problem
BG Test often
Conclusion
 A pump offers the latest technology for precise
insulin delivery
 "Making the insulin pump available to Medicare
beneficiaries will improve the quality of their lives.
The infusion pump offers them a choice to better
control their condition so that they are more active
and productive,"
 Benefits include more flexibility, less
hypoglycemia, improved control, and a longer,
healthier lifespan
 Make the commitment and start pumping!
If you are diabetic &
use
and
Make ur
life
References
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A Randomized Trial Comparing Continuous Subcutaneous Insulin Infusion of
Insulin Aspart Versus Insulin Lispro, DIABETES CARE, VOLUME 31, NUMBER
2, FEBRUARY 2008
Insulin pump use in pediatrics, DIABETES CARE, VOLUME 30, NUMBER 6,
JUNE 2007
Classification of Distinct Baseline Insulin Infusion Patterns in Children and
Adolescents With Type 1 Diabetes on Continuous Subcutaneous Insulin
Infusion Therapy, DIABETES CARE, VOLUME 30, NUMBER 3, MARCH 2007
Comparison of apolipoprotein B100 metabolism between continuous
subcutaneous and intraperitoneal insulin therapy in Type 1 diabetes, Journal
of Clinical Endocrinology & Metabolism. published August 9, 2005 as
doi:10.1210/jc.2005-0989
Bret berner, Steven M.Dinh: Electornically Controllede Drug Delivery.
Attia, N.; Jones, T.W.; Holcombe, J.; and Tamborlane, W.V.: “Comparison of
human regular and lispro insulins after interruption of continuous
subcutaneous insulin infusion and in the treatment of acutely
decompensated IDDM”. Diabetes Care, Vol. 21, No. 5: pp. 817–21, 1998.
Comparison of Quality of Life in Diabetics Using Insulin Injection Therapy
versus Subcutaneous Insulin Infusion Therapy by Katie Michele Reynolds et
al 2007 Ypsilanti, Michigan
References
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McCall A. In: Insulin Therapy. Leahy J, Cefalu W, eds. New York, NY:
Marcel Dekker, Inc; 2002:193
Jay S. Skyler, MD, MACP; Steven Ponder, MD, FAAP, CDE Is There a
Place for Insulin Pump Therapy in Your Practice? Volume 25, Number
2, 2007 • CLINICAL DIABETES
www.delteccozmo.com
www.diabeticcare.com
www.childrenwithdiabetes.com
www.diabetesnet.com
www.animascorp.com
www.myomnipod.com
www.minimed.com