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The Power Of The Pump

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Lesli Staton, MS,RD,CDE. Diabetes Care Consultant, Insulin Pump Specialist

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The Power Of The Pump

  1. 1. The Power of the Pump Optimizing Diabetes Control with your Insulin Pump Presented by: Lesli Staton, MS,RD,CDE
  2. 2. Course Content <ul><li>Optimizing Basal </li></ul><ul><ul><li>Fine tuning basal rates </li></ul></ul><ul><ul><li>Use of alternate and temp basal features </li></ul></ul><ul><li>Optimizing Bolus </li></ul><ul><ul><li>ICR and ISF </li></ul></ul><ul><ul><li>Timing of Bolus </li></ul></ul><ul><ul><li>Basal Bolusing </li></ul></ul><ul><ul><ul><li>Disconnect </li></ul></ul></ul><ul><ul><ul><li>Super Bolus </li></ul></ul></ul><ul><li>Carb Counting </li></ul><ul><li>BG Testing </li></ul>
  3. 3. The Power of Basal Rates The goal is to try and duplicate the body’s natural pattern of insulin secretion. 24 hour background or continuous insulin delivery covering glucose released by the liver. Most pumpers have between 2 to 10 basal rates changes throughout a 24 hour period. Blood glucose should remain relatively stable when fasting if basal rates are set appropriately. Basal patterns must be isolated in order to evaluate……
  4. 4. Basal Rates Testing <ul><li>Isolate Basal Rates: allow 4 hours after a meal or bolus before testing. This insures that there is no active insulin or undigested carb affecting your blood glucose. </li></ul><ul><li>Test Blood Glucose : BG should be between 100 and 150 before starting test . </li></ul><ul><li>Continue Monitoring Blood Glucose: test BG’s every 1-2 hours for the next 4-8 hours. </li></ul><ul><li>Record BG’s: keep a record of time and results to evaluate later and share with your health care provider. </li></ul>If you experience hypo or hyperglycemia during test, stop test and wait a minimum of 24 hours before retesting.
  5. 5. Evaluate Basal Test Results <ul><li>If basal rates are set appropriately, BG’s should not fluctuate more than 30 mg/dl during testing. </li></ul><ul><li>If BG drops more than 30 mg/dl, decrease the basal rate 2-4 hours before the change occurs. </li></ul><ul><li>If BG rises more than 30 mg/dl, increase the basal rate 2-4 hours before the change occurs. </li></ul><ul><li>Adjustments should be no more than a 5 to 10% increase or decrease. </li></ul><ul><li>Retest - basal rate testing is a “work in progress”. </li></ul>Discuss with your health care provider before making any changes to your basal patterns.
  6. 6. Alternate Basal Profile <ul><li>Allows pumper to set a variety of basal profiles which can be alternated between without making adjustments to standard profile </li></ul><ul><ul><li>Regularly Scheduled Changes in Activities </li></ul></ul><ul><ul><li>Weekends </li></ul></ul><ul><ul><li>Sick Days and Menses </li></ul></ul><ul><ul><li>Travel (changes in time zones) </li></ul></ul><ul><ul><li>Basal Testing (allows pumper to test rates </li></ul></ul><ul><ul><li>without making changes to standard profile) </li></ul></ul><ul><li> </li></ul>
  7. 7. Alternate Basal Profile Now Anna utilizes a separate basal pattern designed specifically for this activity. Anna switches to her “yoga” basal pattern every M,W, and F, eliminating the need for extra carb and calories. Anna practices yoga every Monday, Wednesday and Friday from 6pm to 8pm. Before starting on the pump, Anna needed to eat an extra 60g carb before the class to avoid hypoglycemia. in Practice
  8. 8. Alternate Basal Profile Cal utilizes his alternate basal pattern feature by switching to a pre-set weekend basal every Friday night and then back to his standard basal profile on Sunday evening. Meet Cal, banker by week, cowboy by weekend…..every weekend. Because Cal is very active on the ranch, his weekend basal insulin requirements are far less than what is needed on weekdays at the office. in Practice
  9. 9. Temporary Basal Rate <ul><li>Allows the pumper to adjust the standard basal rate for a temporary period, often short-term </li></ul><ul><li>Rate can be altered for 1 - 24 hours depending on need </li></ul><ul><li>Rate change is immediate </li></ul><ul><ul><li>Exercise or unplanned activities </li></ul></ul><ul><ul><li>Travel </li></ul></ul><ul><ul><li>Stress </li></ul></ul>
  10. 10. Temporary Basal Rate Jake is a “skateboard junkie”. He often meets his friends after school, but not always at the same time or day. He has experienced low BG in the past while skateboarding but knows that if he takes his pump off, BG creeps up too high. Using a temporary basal rate, Jake can reduce his basal before the activity, during the activity and about 1-2 hours following the activity without permanently altering his standard profile. in Practice
  11. 11. The Power of the Bolus A rapid surge of insulin delivered at will by pumper “on demand” Covers carbohydrate and corrects for highs by using internal pump calculator Smart pump features allows the pumper to fine-tune bolus delivery by using customized ratios
  12. 12. Insulin to Carb Ratio (ICR) The amount of insulin needed to cover carbohydrate This feature creates more flexibility by allowing the pumper to eat just about any carb at any given time More specifically, the ratio of the amount of carb (in grams) that 1 unit of insulin will cover
  13. 13. Insulin to Carb Ratio (ICR) An accurate ICR returns BG to within 30 mg/dl of your starting BG within 3-5 hours after eating Example: Using a 1:15 ICR, you eat 60 grams of carb… 60/15 = 4 units Total carbs are divided by the ICR to determine insulin dose ICR varies from person to person and should be tested
  14. 14. Prepare to Test your ICR <ul><li>Basal rate testing should be completed before starting bolus testing. </li></ul><ul><li>Allow a minimum of 4 hours after a meal or bolus before testing. You should be isolated to basal insulin. </li></ul><ul><li>Test BG before meal. Pre-meal BG should be 70-150 mg/dl. </li></ul><ul><li>Eat a well-balanced meal of 45-75g carb. The amount of carb must be known and counted accurately. </li></ul><ul><li>Test BG every hour for the next 4 to 5 hours. </li></ul>
  15. 15. Evaluate Your ICR 300 200 100 0 Hours 1 2 3 4 5 Healthy range showing small surge 1-2 hours after meal. BG at 4 and 5 hours within 30 mg/dl of starting BG BG in mg/dl
  16. 16. Evaluate Your ICR <ul><li>It is normal for BG to typically rise 40-80 mg/dl in 1 to 2 hours </li></ul><ul><li>BG at 4-5 hours should be around 30 mg/dl within starting BG </li></ul>Dose too heavy Decrease bolus by increasing ICR value Dose not adequate Increase bolus by decreasing ICR value Evaluate Retest using 1:16 ICR Retest using 1:14 ICR Action Required 81 178 BG at 4 hours Sample: ICR 1:15, Starting BG 120
  17. 17. Insulin Sensitivity Factor (ISF) The amount of insulin required to bring BG to goal More specifically, the ratio representing how much much one unit of rapid-acting insulin will drop BG. Often referred to as a correction factor. This feature creates more flexibility by allowing the pumper to adjust or correct BG at any given time
  18. 18. Prepare to Test your ISF <ul><li>Basal rate testing should be completed before starting bolus testing. </li></ul><ul><li>Allow a minimum of 4 hours after a meal or bolus before testing. You should be isolated to basal insulin. </li></ul><ul><li>May be more difficult to set-up as BG should be above target, requiring a correction bolus. </li></ul><ul><li>Dose for correction based on pump recommendation. </li></ul><ul><li>Test BG every hour for the next 4 to 5 hours. </li></ul>
  19. 19. Evaluating Your ISF <ul><li>It is normal for BG to typically rise 40-80 mg/dl in 1 to 2 hours </li></ul><ul><li>BG at 4-5 hours should be around 30 mg/dl within starting BG </li></ul>Dose too heavy Decrease bolus by increasing ISF value Dose not adequate Increase bolus by decreasing ISF value Evaluate Retest using 1:55 ISF Retest using 1:45 ISF Action Required 63 164 BG at 4 hours Sample: ICR 1:50, Starting BG 221, Goal 120 mg/dl
  20. 20. Timing Your Meal Bolus It is very important that bolusing occurs before the meal. Carb has an immediate effect on BG while rapid insulin reacts in 10-20 minutes. Bolus-as-you-go. To avoid the old trap of “feeding your insulin”, bolus for carb throughout the meal. Be sure to get at least half of the anticipated amount before starting the meal. To maximize results, bolus 10-15 min before meal. If dining out, wait until meal is served.
  21. 21. Basal Bolusing <ul><li>Disconnect </li></ul><ul><ul><li>pump failure </li></ul></ul><ul><ul><li>desire time off pump </li></ul></ul><ul><li>Super Bolus </li></ul>Transfer background insulin to meet immediate demands
  22. 22. Disconnect What: Basal insulin is redistributed as a bolus allowing the pumper up to 4 hours off pump. When: Pump failure or the pumper may desire time off of pump for activities. How: Pumper determines amount of time to disconnect. Basal insulin is calculated and reduced if necessary then taken as bolus to cover basal needs. Pump is disconnected. Do not reconnect to pump until bolused insulin has cleared (4-5 hours). Insulin stacking could occur. Discuss with healthcare provider.
  23. 23. Disconnect Amy is planning a day at the beach and would like to be “untethered” from her pump for the day. Her basal rates are as follows: 12a .85, 3a .95, 7a .80, 9p .85. Amy arrives at the beach at 10a. She calculates her 4 hour basal insulin needs as 3.20 u (0.80 x 4). She anticipates activity so reduces the dose by half. Amy checks her blood sugar and corrects if needed. She then boluses 1.60 units through her pump, disconnects and places her pump in a dry, room temperature environment. Amy continues to check her BG regularly. After lunch, Amy continues this schedule by calculating further anticipated missed basal insulin and reducing the dose for activity. At 2pm, Amy is ready for lunch. She re-attaches her pump, tests her BG and boluses for correction if needed plus the amount needed to cover lunch. in Practice
  24. 24. Super Bolus What: The Super Bolus is a creative method for maximizing BG control by bolusing the basal insulin to cover carb. When: High glycemic foods consistently causing post meal spikes and possible delayed hypoglycemia. How: Basal insulin is reallocated and added to the pre-meal bolus thus intensifying the amount of upfront insulin.
  25. 25. Super Bolus Jim loves his wives home-made bread. Problem is that it consistently spikes his BG and causes delayed hypoglycemia . Using a “Super Bolus”, Jim maximizes his outcomes. Before indulging in a 45g slice of bread, he adds 3 hours of basal rate to the total and turns off basal delivery. With an ICR of 1:15 and a basal rate of 1.1u/hr, Jim boluses 6.3u for the bread. He uses the temp basal feature to zero out his basal rate for the following 3 hours. In Practice
  26. 26. Insulin on Board Bolus on Board Feature that prevents pump from stacking insulin by tracking previous bolus and adjusting for any residual amount. Insulin on board Bolus on board Active insulin Duration of active insulin Typically set for 3-4 hours Be familiar with your pump and how it calculates BOB Pumps vary
  27. 27. Trending Do not make adjustments to settings based on one event. Look for trends. Plot your course. Record the following: <ul><li>Blood Glucose </li></ul><ul><li>Boluses </li></ul><ul><ul><li>Differentiate between carb and correction bolus </li></ul></ul><ul><li>Exercise or activity </li></ul><ul><li>Stress, illness, menses </li></ul><ul><li>Infusion set and cartridge change </li></ul><ul><li>Utilize pump flow sheets </li></ul>
  28. 28. Basic Concepts Revisited Carb Counting All the therapeutic features presented here are futile if carbs are not counted accurately. Practice, practice, practice Take a class, visit with a dietitian, weigh, measure, plan . Blood Glucose Testing Insulin Pump Therapy requires a significant amount of BG testing: fasting, premeal, post meal, bedtime, 3am Accuracy is critical. Insure that strips are current. Use control solution. Select a high quality product.
  29. 29. Stay Informed

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