Janana

1. Pumping
How Do I Start?
John Walsh, P.A.
Author: Pumping Insulin, Using Insulin
(619) 497-0900 www.diabetesnet.com

2. What We’ll Cover
 Introduction to pumps
 Advantages of pumping
 Am I a candidate?
 How to choose a pump and infusion set
 What is needed to start
 Importance of data
 Site preparation
 Troubleshooting
 Formulas that help
 Smart features

3. Where Pumps Began
 Started ~1978 with conversion of
portable chemotherapy pumps to
delivery of insulin
 The Autosyringe AS2C and Harvard
Apparatus Mill Hill Infuser were first
 Single basal, no memory
 50 ml syringe on pump exterior
 Required dilution of insulin
to U-36 or U-18
1976 Biostator (top) and 1978 Autosyringe AS2C –>

4. The Basal-Bolus Concept

5. Advantages
 Flexibility in meal timing & size
 Eat when you want to
 Faster adjustment of
insulin for exercise
 Family activities are no longer tied to
one person’s needs
 Easier handling of illness, travel, or
camping

6. Advantages
More Consistent Insulin Action
 The same dose of NPH
insulin given to the same
individual varies by 25%
from day to day
 Order of variablility:
NPH > Lente > Lantus >
Detemir
 A pump has less variable
insulin delivery at 3%

7. Advantages
 Precise doses, as small
as 0.025 u, can be given
 Manages the Dawn
Phenomenon
 Improves control during
growth spurts and
adolescence
 Reminders

8. Who Is A
Good Pump Candidate?

9. Why Choose A Pump?
 A freer lifestyle
 Easier dose determinations
 Improved blood sugars
 Flexibility in meal timing and size
 Ability to exercise without losing control
 Peace of mind

10. When To Consider A Pump
 More than 3 injections per day
 Tired of multiple injections
 Frequent or severe hypoglycemia
 Hypoglycemia unawareness
 Elevated A1c
 DKA or ER/hospital admission
 Strong Dawn Phenomenon
 Require small, precise doses
 Less risk of complications

11. Insulin Pump
Pro
 Less work
 Simplified insulin dosing
 Precise delivery
 Greater impact in those
with highest starting A1c
 Slightly less insulin use
per day
Con
 More DKA
 More severe
hypoglycemia
 A1c levels and
frequency of DKA &
hypoglycemia are
similar to ICT

12. What It Takes To Succeed
 A personal desire for better control
 Willing to adjust insulin doses to carb
count, test results, and activity
 Willing to monitor at least 4 times a day
 Willing to keep an accurate record of
BGs, boluses, and carb counts
 Committed to solve problems and adapt
lifestyle as needed

13. Success For Kids On Pumps
 Supervision is required: kids BEGIN to
develop self care skills at about age 10
 Family support is essential: an adult who can
go to school, etc.
 Communication with a health care team that is
committed to pumps
 Adequate insurance and financial resources
 Assistance and support from teachers,
friends, babysitters, grandparents, siblings

14. Features For Infants & Toddlers
 Little ones are ideal pump candidates if the
parents are
 Delay or split boluses for fussy eaters
 Small, user-friendly pumps offer precise
dosing (0.05, 0.025, or 0.01 unit increments)
 Lock out
 Worn between shoulder blades
 If a toddler likes to remove the
infusion set, let them know what
comes out must go right back in

15. Help For Kids & Teens
 Growth spurts
 Dawn Phenomenon
 Easy coverage of snacks
 TDD and bolus history can be checked
to ensure consistent dosing
 Faster adjustment of basals and boluses
for changes in activity, etc

16. Special Teen Concerns
 Dating
 Wearing, sharing
 Alcohol
 Eating disorders
 Fast foods
 Fabrication
 Sleeping-in

17. Personal Effort
Those who expect a pump
to manage their diabetes
for them will fail to
optimize their own
therapy.
Learn how to adjust your basals and boluses
for an excellent A1c!

18. First Steps Toward A Pump
 Keep detailed records
 Consider your (and your child’s) motivation
 Peer group, acceptance issues, family support
 Look at available pumps
 Which pump(s) does your insurance cover?
 Talk with your doctor about a prescription
 Visit a dietician to learn carb counting

19. What To Learn
 How your pump works
 How to count carbs
 How to interpret BG results
and see BG patterns
 When to increase and
decrease basals and boluses
 How to adjust for high GI foods, extra
activity

20. How To
Choose A Pump

21. Pump Companies
Who sell or plan to sell
pumps in the US:
 Animas R1200
 Dana Diabecare III
 Deltec Cozmo
 Medtronic Paradigm
 Nipro Amigo
 Roche/Disetronic
Visit www.diabetesnet.com/diabetes_technology/

22. Things To Consider
 Look, feel, color
 Features: reminders, child block, waterproofing
 Size of basal and bolus increments
 Infusion set choices
 Safety and reliability
 Customer support
 History
 Ease of data analysis
 Add-ons: meters, covers, cases

23. Today’s Smart Pumps
 Easy dose calculations with Carb Factor
and Correction Factor
 Precise insulin dosing (0.05 units or better)
to allow basal rates to be set up for Dawn
Phenomenon, etc.
 Tracks BOB to avoid insulin stacking
 Reminders

24. Today’s Pumps
 When control is poor or varies greatly on
one of today’s pumps, the pump settings
are incorrect.
 Test and reset basal rates, carb and
correction factors until you have good
control.
 Garbage in…..

25. How To Choose
An Infusion Set

26. Infusion Sets
 Straight-In Teflon: Cleo, Inset, Ultraflex, Quik-Set
 Easier to insert, variety of depths (6, 8, 9 mm)
 Angled Teflon (Comfort, Tender, Easy, Silhouette):
 Fewer failures
 Insertion site is visible
 Longer is more secure
 Adjust angle to reach fat
 Metal needles (Rapid-D or bent needle)
 As comfortable and often more reliable
 Very short, multi-needle infusion sets expected soon

27. Infusion Sets And Inserters
Smith’s Medical Cleo
Medtronic Sil-serter
Disetronic Rapid-D
Animas Inset
Quik-serter

28. Site Supplies
 Emla cream (Rx, 30 min wait) or ice cube
 Set inserter: Cleo and Inset are self-contained,
ezSerter, Quick-Serter, Sil-Serter, Sof-Serter
 Adhesive: IV-3000, Hypafix, Tegaderm
 Stickies: Skin Tac-H, Skin Prep
 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

29. School Supplies
 Meter, lancets, test strips
 Glucagon, glucose tablets, or
crackers for lows
 Spare insulin, syringes or insulin pen
 Spare infusion set and pump batteries
 Ketostix or Precision Xtra to test for ketones
 Information card with insulin-to-carb ratio,
formula for corrections
 Telephone numbers of parents, health care
providers, and pump manufacturer's help line

30. How To Start

31. Starting On A Pump
 Everyone is nervous
 Read, read, read
• Pumping Insulin, Kids Insulin Pumps And You
(Animas), www.childrenwithdiabetes.com,
www.pumps4kids.ca, etc, etc
 Do lots of recording before and after start
 Start to play with pump as soon as it arrives
 Saline practice helps
 Get telephone contacts: MD, CDE, pump
company, pump rep, other parents

32. 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
 Write down a reason for every low and high
 Test often

33. John’s Pump Rules
• Total Daily Dose = weight in lbs / 4
• Basal Dose = 50% to 60% of TDD
• Carb Factor = 500 / TDD
• Correction Factor = 2000 / TDD
• BG target = 90 to 120 mg/dl
• Basal target = +/- 30 mg/dl
• BOB = 20% per hour
• Correction boluses = < 8% of TDD
J Walsh and R Roberts: Pumping Insulin, 2005

34. Starting Insulin Doses
J Walsh and R Roberts: Pumping Insulin, 2005

35. Carb Counting And Recording
As Ways To Lower The A1c

36. Steps For A Better A1c
 Carb counting – 0.6%
 Givivg boluses based on an accurate carb count
– 0.3%
 Recording test results, carb intake, insulin
doses, & activity – 0.5%
 Monitoring often – 0.5-2.0%
 Bolusing often – 0.5-2.0%
 Contacting your doctor or adjusting your own
doses when you encounter unwanted BGs

37. Carb Counting
 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!

38. Where Carbs Come From
 fruit/fruit juice
 breads/bagels
 cereals
 crackers
 grains
 muffins
 rice
 potatoes/yams
 vegetables
1 gram of carb
raises the BG
4 to 7 points!
 dessert/cookies/cake/pie
 ice cream/frozen dessert
 sweetened beverages
 milk/yogurt (not cheese)
 beer/wine
 honey/syrup/molasses
 jams/jellys/preserves
 -ose foods like sucrose
(table sugar)

39. How To Count Carbs
 Food labels
 Check portion size
 Books
 Dr’s Pocket Guide, Health Cheques
 A gram scale plus carb factors
 Carb factors are available in Pumping
Insulin and are built into scales like the
Salter computer gram scale

40. Blood Sugar Testing – 1921

41. Blood Sugar Testing – 2004

42. Blood Sugar Testing – 2004
“I just don't write down (log) anything. I hate to take
the time to do it. I'd rather have a machine talk for
me. I think it revolves around partial general laziness,
as well as the constant reminder of being different
from everyone else. I know other diabetics who won't
even test when they're out with friends. They hate
….”
The Artiste 6/28/04

43. Smart Charts
 Needed to solve
problems
 Basis for better
diabetes health care
 ~0.5% drop in A1c
Blood sugar, insulin, food, activity, stress
Charting Improves Control

44. Better Charts, Better A1c
 Charts
 My Other CheckBook
 Software
 Meter companies
 Internet: myhealthchannel.com
 Pump Control Software
 Meters, PDAs & Pumps
 Pump: Deltec, Disetronic, Animas, Medtronic
 Meter: BD, Therasense, Lifescan, Boerhinger

45. Analyze Carb Boluses
1. Count carbs
2. Give carb bolus
3. Eat
4. Record BGs
5. Analyze BGs
6. Balance better next time

46. Match Your Carbs With Boluses
 Accounts for HALF the day’s control!
 Keeps blood sugar normal after meals
 Requires accurate carb counting and an
accurate carb factor
 500 Rule provides a close estimate of
carb factor if the TDD is accurate

47. 500 Rule To Find Carb Factor
 Gives grams of carb covered by one unit of
Humalog or Novolog
 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
 Postmeal readings stay normal!

48. 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
Adapted from 1500 Rule by Dr. Paul Davidson, Atlanta, GA

49. 2000 Rule
Total Daily Dose Point drop per unit
20 units 90 pts
25 units 72 pts
30 units 60 pts
35 units 51 pts
40 units 45 pts
50 units 36 pts
60 units 30 pts
75 units 24 pts
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

50. New Devices
 Data storage and download
 Easy recording of BGs,
insulin, carbs, activity
 Automatic carb counting
 Pattern recognition
 Insulin dose guidance
 Data analysis to improve control
 Feedback that encourages use

51. Pump — Meter Combos
 CozMonitor from Deltec
and Therasense
 Disetronic and Roche
 Medtronic 512 and BD
Paradigm Link
 Animas and Lifescan
 Dana Diabecare III and
Dana meter

52. Troubleshooting

53. Most Pump Problems Occur In
First week
 First month
 First 6 months
Problems are most likely when
unexpected or inconvenient

54. Occasional Pump Problems
 Setup tips
 Leaks
 O-rings
 Hub
 Line
 Clogs
 Site infections
and abscesses
 Allergies
 Bleeding
 onto skin
 inside needle
 under skin
 Pump bumps
 Hypertrophy
 DKA
Some frustration at times is normal!

55. Set And Site Issues
Dislodged infusion set
Tunnelling
 Rapid-D and slanted Teflon sets
work better for mobile kids
 Metal may be better than teflon
Infection
Hematoma

56. 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

57. Will Your Pump Alarm?
Low battery
Mechanical problem
Empty reservoir
Clog
Forgotten bolus
Leak
Bleeding
Bad programming
Dislodged infusion set
Yes
Yes
Yes
Yes
Yes
No
No
No
No

58. How To Check Mechanical Problems
Check from
skin to pump:
Skin and site
Infusion set
Connection
Line
Hub
Reservoir
Pump

59. High BG Checklist
 See a leak or smell insulin?
 Infusion set in place?
 Was infusion set primed?
 Are connections at hub and O-rings tight?
 Bubbles in the tubing? One inch = a half unit
 Clog in line?
 Alarms? Errors?
If no cause is found, replace everything!

60.  Test for all BGs over 300
 Always test when nauseous
 Test urine with Ketodiastix
 Test blood with Precision Xtra meter
 Earlier detection
 No need to collect urine
 Keep currently dated strips available
Go to ER at 1st sign of vomiting!
Check Ketones Early

61. More Insulin For
Unexplained High BGs
 When a blood glucose test is unexpectedly
high, the correction bolus needed to lower
this will be much higher than normally
required
 Loss of basal insulin delivery for several hours
 Insulin resistance from length of
hyperglycemia
 Insulin resistance from presence of ketones

62. Conclusion
 A pump offers the latest
technology for precise insulin
delivery
 Requires commitment and
responsibility
 Benefits include more flexibility,
less hypoglycemia, improved
control, and a longer, healthier
lifespan
 Make the commitment and start
pumping!

63. Questions
???