1. Insulin Pump Therapy Celia Levesque RN, NP-C, CNS-BC, CDE, BC-ADM

2. What is an insulin pump? • A machine that is surgically implanted that automatically delivers insulin • A machine that the patient changes the infusion set and programs it to deliver insulin • A machine that delivers insulin automatically based on the blood glucose 0

3. First insulin pump

4. Accuchek Combo

5. Animas

6. Medtronic

7. OmniPod

8. Tandem

9. V Go

10. Reservoir

11. Infusion sets

12. Infusion Set

13. Angle insertion catheters

15. How often should the infusion set be changed? • Every 3 days or less • If the infusion set is painful • If the BG is not well controlled • All of the above 0

16. Bent Infusion Set

17. Sites

18. Indications for Pump Therapy • Poor HbA1c • Frequent low blood glucose • Dawn phenomenon • Exercise • Pediatrics • Pre-Conception Years and/or Pregnancy • Gastroparesis (slow digestion) • Hectic lifestyle • Shift work • Type 2 DM on insulin

19. Insulin Pump Candidates Anyone who: • Uses insulin • Willing to check blood glucose • Desires pump therapy • Capable of operating the pump

20. Insulins • Rapid Acting • Short Acting • Intermediate Acting • Long Acting

21. What kind of insulin goes in the pump? • Rapid acting • Short acting • Intermediate acting • Long acting 0

22. Normal Insulin Secretion

23. Rapid Acting Novolog/aspart Humalog/lispro Apidra/glulisine Onset: 20 minutes Peak: 1.5 hour Duration: 4-5 hours

24. Regular: Short Acting Onset: 1 hour Peak: 2-4 hour Duration: 6-8 hours

25. Insulin Pump Doses Current Total Daily Dose Reduce by 25% 50% Basal 50% Bolus Divide by 24 Divide by 3

26. Insulin to CHO ratio • Insulin to carbohydrate (CHO) ratio (I:C) is the number of grams of CHO per 1 unit of short or rapid acting insulin • To calculate a starting insulin to carbohydrate ratio • 500 ÷ Current total daily insulin dose • This rule works if approximately half of total daily insulin dose is basal and half is bolus

27. “… Doctor, I have a Billy Roberts on line two who wants to know how much insulin he needs to take to cover 6 malt balls… 3 Chocolate bunnies… 11 marshmallow eggs… oh.. and a whole handful of gummi worms…”

28. Total Carbohydrate Includes grams of sugar, sugar alcohol, starch, and dietary fiber. Serving SizeGrams of total carbohydrates, multiplied by number of servings = total grams of carbs Nutrition Label Adapted from Warshaw, H.S., Bolderman,K.M.; ADA, 2001 p 13

29. Sensitivity Factor • The mg/dl that 1 u rapid acting insulin will decrease BG • Also called correction factor • Math Formula • 1500 Rule: 1500 ÷ TDD • 1700 Rule: 1700 ÷ TDD • 1800 Rule: 1800 ÷ TDD • 4.4 x carb ratio

30. Assessment of Patient • Type of diabetes • Duration of diabetes • Complications from diabetes • Current blood glucose • Recent history of control • When the infusion set was last changed • What does the site look like

31. Assessment of Patient • Type of insulin used in the pump • Pump settings • Last bolus • Is the patient or significant other capable of caring for the pump • Is the patient going to have an MRI or surgery that will involve the pump site?

32. If the BG is > 250 mg/dL, what should be done next? • Bolus for the high BG • Wait 1 hour and recheck • Nothing, the pump will correct the BG 0

33. IF BG >250 mg/dL • Bolus for high BG • Recheck BG in 1 hour

34. If 1 hr recheck > 250 mg/dL • Give rapid acting insulin immediately via insulin syringe • The dose is based on the sensitivity factor and target BG • Recheck the BG in 1 hour • Have the patient change the infusion set with fresh insulin • Continue monitoring blood glucose every 1-2 hours until stable

35. If 1 hr recheck > 250 mg/dL • If you give Regular insulin, you can’t recheck and give additional Regular insulin for 3-4 hours • Do NOT give IV Regular insulin bolus • Can start an insulin drip if the patient is dehydrated or in DKA

36. Remove the pump if: • The patient can’t operate the pump safely • If the patient needs to change the infusion set but does not have supplies • If the patient is having an MRI • Need to immediately give the patient insulin via syringe when the pump is disconnected

37. Insulin doses for pump removal • Total daily dose via pump • 50% basal insulin given in 1 dose q 24 hrs or 2 divided doses every 12 hours • 50% bolus for food • Sensitivity factor to correct hyperglycemia

38. Check BG at time of removal • Long acting insulin will take 4-6 hours to start working • Check BG every 2 hours and correct hyperglycemia with rapid acting insulin • If BG is falling, don’t give additional rapid acting insulin

39. Example • Mr Jones is a T1DM using an insulin pump • He is unable to care for the pump • BG at time of disconnection is 192 mg/dL • His total daily dose on the pump is 30 units

40. How much basal insulin should be ordered? • 15 units daily • 10 units daily • 30 units daily • 15 units twice daily 0

41. How much rapid acting insulin should be given now? • 1 unit • 2 units • 3 units • 4 units 0

42. Example continued • Basal insulin: 15 units per day • Insulin to carb ratio: 1:15 • Sensitivity factor: 60 • Target BG 80-120 mg/dL

43. How much cho should be given if the bg is 67 mg/dL • 15 grams • 30 grams • 10 grams 0

44. Hypoglycemia • If BG 50-70 mg/dL give 15 gm CHO • If BG < 50 mg/dL give 30 gm CHO • If the patient can’t swallow: • ½ amp D50 IV • 1 mg glucagon for ages > 4 years • 0.5 mg glucagon for ages < 4 years

45. Case study • 52 yo male with T1DM and cancer • Went to ED for fever/sepsis • Pump removed in ED • Serum BG > 800 mg/dL for > 8 hrs • Pt developed DKA and went to ICU • What could have been done to prevent this?

50. Leading Participants