1	Advanced Pump Management Gary Scheiner MS, CDE Integrated Diabetes Services 333 E. Lancaster Ave., Suite 204 Wynnewood, PA 19096 (877) 735-3648 (610) 642-6055 www.integrateddiabetes.com gary@integrateddiabetes.com
2	Advanced Pump Management Basal Insulin Regulation Bolus Regulation Physical Activity Adjustment DKA Prevention Temporary Basal Rates Prolonged Boluses Alternate Basal Patterns
3	Basal Insulin Regulation Basal Insulin’s One And Only Job Is To Hold Blood Glucose Levels Steady In the Absence of Confounding Influences* * Food, Exercise, Bolus Insulin, Unusual Hormonal Conditions (illness, rebounds, menstruation)
4	Basal Insulin Regulation Conditions for Testing Basal Rates: No food or bolus for at least 4 hrs prior Last meal/snack low in fat No food or bolus during test phase (water/diet drinks OK) BG above 80, below 250 throughout No lows for previous 12 hrs Stay connected, no stopping/suspending Exercise OK up until test phase (if usually performed) No heavy activity during test phase Do not run test if sick or just prior to/start of period
5	Basal Insulin Regulation
6	Basal Insulin Regulation
7	Basal Insulin Regulation Currently: .30 3am-9am, .25 9am-3am Skipped Breakfast BG results: 6am 109 8am 201 10am 230 12pm 224
8	Bolus Insulin Regulation I:C Ratios: The correct ratio should match pre-meal BG 3-4 hours (not 2!) after eating I:C Ratio often varies from meal to meal (bkfst dose > lunch & dinner)
9	Bolus Insulin Regulation Correction Boluses: 1500-Rule (aggressive) (Total Daily Ins.)/1500 1800-Rule (conservative) (Total Daily Ins.)/1800 May vary day vs. night (nighttime often 50% more than day)
10	Physical Activity Adjustments
11	Physical Activity Adjustments Meal Bolus Adjustment* Low Intensity Cardio ê 25% Mod. Intensity Cardio ê 33% High Intensity Cardio ê 50% Competitive/Anaerobic ??? * If activity is after meal
12	Physical Activity Adjustments Snacking to prevent low (examples)
13	Physical Activity Adjustments Watch Out for D’OH! (Delayed Onset Hypoglycemia)
14	Physical Activity Adjustments OK To Disconnect Up To 1 Hour w/ Activity
15	Physical Activity Adjustments Alternatives to Disconnection:
16	DKA Prevention Normal Cellular Metabolism
17	DKA Prevention Metabolism With Insulin Deficiency
18	DKA Prevention Progression to DKA
19	DKA Prevention Causes of insulin deficiency in Pump Therapy Malabsorption (site problems) Insulin Spoilage Tubing or infusion set clogs Leaks where the cartridge connects to the tubing “Tunneling”/Leakage at the infusion site Air pockets in the tubing Dislodgement of the canula from beneath the skin Improper or insufficient priming Extended pump suspension or disconnection
20	DKA Prevention
21	Temporary Basal Rates Basal Insulin Should Hold BG Steady Under Normal Conditions. How Often Is Life Under “Normal Conditions”?
22	Temporary Basal Rates High-Fat Food
23	Temporary Basal Rates Illness
24	Temporary Basal Rates Predictable Stress
25	Temporary Basal Rates Extended Inactivity
26	Temporary Basal Rates Menstrual Cycles
27	Temporary Basal Rates Prolonged Activity
28	Temporary Basal Rates Prevention of D’OH! (Delayed-Onset Hypoglycemia)
29	Temporary Basal Rates Alcohol
30	Temporary Basal Rates Offsetting Bedtime Insulin-On-Board
31	Temporary Basal Rates BG Dropping (w/nausea)
32	Prolonged Boluses Description Normal/Standard Boluses are delivered within a few minutes; peak is approx. 1 hr, duration approx. 4 hours Prolonged boluses are delivered over a period of a couple of hours; peak is delayed/blunted and duration is extended.
33	Prolonged Boluses Purpose To do a better job of matching the blood sugar rise caused by slow-digesting foods.
34	Prolonged Boluses Applications Very Large Portions Low-Glycemic-Index Foods Meals/Snacks that take a long time to consume Gastroparesis
35	Prolonged Boluses Options for slow-digesting food: Normal Bolus
36	Prolonged Boluses Options for slow-digesting food: Square/Extended Bolus
37	Prolonged Boluses Options for slow-digesting food: Dual/Combination Bolus
38	Alternate Basal Patterns Called Pattern A/B (Medtronic), Prog 2-4 (Animas), Pattern 1-4 (Deltec) Useful when basal changes are needed for several days (or more) in succession
39	Alternate Basal Patterns Menstrual cycle phases Extended illness Recovery from surgery Periodic use of steroid medications Seasonal sports Off-day vs. work/school-day Extended travel Climate changes
40	The Ultimate Pump Challenge