Notes
Slide Show
Outline
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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
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Advanced Pump Management
  • Basal Insulin Regulation
  • Bolus Regulation
  • Physical Activity Adjustment
  • DKA Prevention
  • Temporary Basal Rates
  • Prolonged Boluses
  • Alternate Basal Patterns
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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)
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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



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Basal Insulin
Regulation
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Basal Insulin
Regulation
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Basal Insulin
Regulation
  • Currently:
  •   .30 3am-9am,
  •   .25 9am-3am
  • Skipped Breakfast
  • BG results:
    • 6am 109
    • 8am 201
    • 10am 230
    • 12pm 224

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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)


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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)



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Physical Activity
Adjustments
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Physical Activity
Adjustments
  • Meal Bolus
  • Adjustment*
  • Low Intensity Cardio    ę 25%
  • Mod. Intensity Cardio   ę 33%
  • High Intensity Cardio   ę 50%
  • Competitive/Anaerobic ???
  • * If activity is after meal
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Physical Activity
Adjustments
  • Snacking to prevent low (examples)
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Physical Activity
Adjustments
  • Watch Out for D’OH!
  • (Delayed Onset Hypoglycemia)
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Physical Activity
Adjustments
  • OK To Disconnect Up To 1 Hour w/ Activity


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Physical Activity
Adjustments
  • Alternatives to Disconnection:
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DKA
Prevention
  • Normal Cellular Metabolism
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DKA
Prevention
  • Metabolism
  • With
  • Insulin
  • Deficiency


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DKA
Prevention
  • Progression
  • to DKA
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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

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DKA
Prevention
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Temporary
Basal Rates
  • Basal Insulin Should Hold BG Steady Under Normal Conditions.


  • How Often Is Life Under “Normal Conditions”?
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Temporary
Basal Rates
  • High-Fat Food


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Temporary
Basal Rates
  • Illness


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Temporary
Basal Rates
  • Predictable Stress


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Temporary
Basal Rates
  • Extended Inactivity


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Temporary
Basal Rates
  • Menstrual Cycles


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Temporary
Basal Rates
  • Prolonged Activity


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Temporary
Basal Rates
  • Prevention of D’OH!      (Delayed-Onset Hypoglycemia)


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Temporary
Basal Rates
  • Alcohol


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Temporary
Basal Rates
  • Offsetting
  • Bedtime
  • Insulin-On-Board


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Temporary
Basal Rates
  • BG Dropping                   (w/nausea)


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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.


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Prolonged
Boluses
  • Purpose
  • To do a better job of matching the blood sugar rise caused by slow-digesting foods.


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Prolonged
Boluses
  • Applications


  • Very Large Portions
  • Low-Glycemic-Index Foods
  • Meals/Snacks that take a long time to consume
  • Gastroparesis


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Prolonged
Boluses
  • Options for slow-digesting food:
  • Normal Bolus
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Prolonged
Boluses
  • Options for slow-digesting food:
  • Square/Extended Bolus
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Prolonged
Boluses
  • Options for slow-digesting food:
  • Dual/Combination Bolus
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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



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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



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The Ultimate
Pump Challenge