Slide Deck for the 2014 School RN talk on Insulin Pump use by Stephen Ponder MD, FAAP CDE on June 21, 2014 in Austin, Texas at the TypeOneNation conference.

1. Advanced Insulin Pumping
(getting your pump to perform its best)
Stephen W. Ponder MD, FAAP, CDE
Professor
Texas Tech Health Sciences Center

2. 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.

3. The “mother of all
pump settings” is the
total daily dose!
(TDD)

4. 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.

5. 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:

6. Doing an at home
pump “pit stop”
 Check pump time
 Download/review bolus
history (time?)
 Download/review meter
and/or log book (time?)
 Review basal rates
 Check for bubbles
 Inspect infusion site

7. 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 factor
IV. A good pump doc is more a
coach (educator) than a
prescriber
V. Simple is always a good start

8. 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 virtue
IX. Success is relative
X. Don’t ever be afraid to start
over

9. 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

10.  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 Outdated pump settings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

11. 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

12. 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!

13. ~2AM to 4AM is the biologic low point for insulin need
~ 40% of hypoglycemia occurs during sleep! It’s often asymptomatic!
Breakfast
Lunch
Snack
Supper
Snack
2-4AM
Breakfast
6–9AM
Snack

14. 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

15. Stop Lows First
Better 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!!!

16. 10 advanced pumping tips
1. 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”

17. . . .
.
.
.
.
.
.
.
2 hours
150 mg/dl
80 mg/dl
135 mg/dl
glucose
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

18. . . .
.
..
.
.
.
.
.
.
2 hours
155 mg/dl
95 mg/dl
125 mg/dl
glucose
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

19. 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
glucose
bolusCHO

20. 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
glucose
bolus

21. Two week pumper log sheet
(complete the open spots)
Influenced
by basal
Influenced
by boluses
Checks
overnight
basal(s)

22. 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…)

23. 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

24. 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

25. 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
glucose
bolus
A modified extended bolus
For treating a high bedtime BG
Calculate correction dose
Deliver it over 5-6 hours
Reduces risk of low BG @ 3AM

26. 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”
glucose
bolusCHO
300 mg/dl
5-6 hours

27. 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

28. 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
glucose
bolusCHO
140 mg/dl
9
0.00 U/hr

29. Superbolus for faster correction

30. . . .
.
..
.
.
.
.
.
.
2 hours
180 mg/dl
80 mg/dl
125 mg/dl
glucose
0.75 U/hr B A S A L
timetime
60 mg/dl
Exercise or other
strenuous activity
Temp basal rates

31. .
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

32. 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

33. 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

34. 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