Practical Aspects of Insulin
Pumping
DeAnn Johnson, RN, BSN, CDE
Susie Owen, RN, CDE
Overview:
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Evidence for pump therapy
Patient selection
Dosing
Set and site issues
Pump attire
Sick Days
Travel
Case study
Discussion
BDC results:
1 year pre CSI compared to ea yr thereafter
HbA1c Values
(1 year pre-CSII compared to each year)
9
n=291
*
n=267
*
n=196
†
n=146
†
n=105
†
n=59
†
HbA1c value (%)
8.5
n=34
†
n=11
†
8
Pre-CSII
Most Recent
7.5
7
6.5
1
2
3
4
5
6
7
8
Years on CSII
*= p<0.001, †=p<0.05. The pre-CSII values for each year represent the initial values
for only those with an HbA1c value in that year.
Chase HP et al, Diabetes Technology& Therapeutics, 9:421,2007
Severe Hypoglycemia and
Insulin Pumps (CSII)
Rate of hypoglycemia
(events per 100 patientyears)
Figure: The Decline of Severe Hypoglycemic Events
with CSII Therapy in a General Clinic Population
14
12
10
8
6
4
2
0
Pre-CSII
*
On CSII
Pre-CSII
**
On CSII
* Maniatis, Chase, et al. ** Scrimgeour, Chase, et al
Pediatri,107,351 2001
D T & T 9:421, 2007
(In DCCT: 62per 100 pt. yrs: NEJM, 329, 977, 1993)
Who’s a good candidate?
Essential Criteria for Pump Initiation
Survey of 54 Diabetes Educators
* All 54 respondents ranked SMBG as an
essential criteria for pump start
Lenhard et. al., Infusystems USA 3, 1, 2006
2007 Consensus Statement on Pump Use in
Peds- Patient Selection
Endorsed by the ADA & European Assoc. for the Study of Diabetes
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Recurrent severe hypoglycemia
Wide fluctuations in bg levels regardless of A1c
Suboptimal diabetes control
Micro/macro vascular complications
Good control but regimen compromises lifestyle
Infants and neonates
Adolescents with eating disorders
Children and adolescents with pronounced dawn
phenomenon
Pregnant adolescents
Ketosis-prone individuals*
Competitive athletes
Children with needle phobia**
Battelino,P.M., Rodriguez,H.D., Kauffman, F. Use of insulin pump therapy in the pediatric age-group: consensus statement from the European Society for
Paediatric Endocrinology, the Lawson Wilkins Society and the International Society for Pediatric and Adolescent Diabetes, endorsed by the American
Diabetes Association and the European Association for the study of Diabetes Care Diabetes Care 2007:30:, 1653-1662
*Blackett PR: Insulin Pump Treatment for Recurrent Ketoacidosis in Adolescence; Diabetes Care;1995;18:891-892.
**Maniatis AK et al, Pediatric Diabetes 2001 June;2(2):51-57.
Basal Dosing
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Half total daily dose. May decrease by 10-30%. Divide
over 24 hours
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Convert Lantus or Levemir dose directly into basal
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Set pump up in 3 hour increments
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Consider dilution to U50 (off label) if using <.05 u/Hr.
To order diluent for Humalog 1-800-821-0538, for Novolog
1-800-727-6500
Keep timing of basal dosing in mind for disconnections
Use alternate increased basals for menses, illness, steroid
use and alternate lower basals for high exercise
days/nights
Basal Dosing Needs
B and C= 708 and 83 primarily pubertal subjects
D = 152 subjects
F = 117 pre-pubertal subjects
From Holterhus PM, et al., Diabetes Care, 2007; 30(3):568-73.
Bolus Dosing
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Consider using “Rule of 500 (carbs)
& Rule of 1700 (correction)”
Bolus 15-30 minutes prior to meal
Dual Wave Bolusing
Change in blood glucose levels (mmol/L)
5
4
3
2-hour post-prandial
2
4-hour post-prandial
1
0
-1
1 Bolus
2 boluses
Square wave
Dual Wave
Method of bolus administration
Mean change in blood glucose levels following four methods of
bolus administration. (Chase HP et al. Diab Med 19:317, 2002.)
Use of the Combination or Dual
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Useful for all high fat/ high carb meals
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May add a unit to total bolus to combat decreased insulin
sensitivity
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Starting point: Take ½ (50%) of bolus immediately and
extend the other half (50%) over the next 2 hours
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Check bg at 2,4 and 6 hours
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Make
 >
 <
 >
adjustments as needed (examples):
180* at 2 hrs. =  to 60% Immediate bolus
70* at 2 hrs. =  to 40% Immediate bolus
180* at 4 hrs. =  to 60% Extended bolus
*180mg/dl =10mmol/L
Forgotten Boluses –
Increase of a half point in A1c if just 2 boluses missed
per week!*
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Use of pump alarms
Cell phone alarm
“Food in mouth, hand
on pump!”
Upside down plate
Bolus for all carbs
(except tx of lows)
Parental review
Evaluate for eating
disorder
*Chase HP, et al: Pediatrics 113,221,2004
Exercise
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Jason Johnson, a
pitcher for the Detroit
Tigers was diagnosed
with Type 1 Diabetes
when he was 11.
The MLB approved use
of insulin pumps during
games in 2004.
Exercise Dosing
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Disconnect for duration. Test every 2 hours
minimum. May need 50% bolus predisconnection for anticipated missed basal +
correction and additional corrections throughout
activity.
25-75% decreased temp basal during moderate
to intense extended duration activity. May start
up to an hour prior.
25-75% reduction to alternate basal for delayed
hypoglycemia during the night starting 2 hours
prior to expected drop.
Potential 25-75% decrease to bolus just prior to
activity and/or immediately following.
Choosing the Right Site and Set
Site and Set Considerations
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Pinch test
Hypertrophy/lipoatrophy
Curves
Disconnection access
Diapers
Activities
90 Degree Infusion Sets
Cleo
Inset
Quick set
Rapid D
Sure T
Angled Infusion sets
Inset 30
Comfort
Silhouette
Tender
Omnipod
Minimize Pain and Anxiety
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Desensitization:
breathing/
distraction/
visualization –
bubbles, I Pod
Use of inserter
Use of buttock/hip
Parent wears at
saline start
Respect rituals
Maniatis AK et al, Pediatric Diabetes 2001 June;2(2):51-57.
Numbing agents
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ice – teething rings,
cold stones
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Gigi Waxing Spray
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L-M-X4
Emla crème, generic
lidocaine 2.5%
/prilocaine 2.5% crème
(discs or use with wax
paper)
Where to wear?
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alana-mireilleapparel.com
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Kangaroo Pump Pockets
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Mypumpgear.com
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Pumpwearinc.com
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store.minimed.com
Wearing the Pump
Cell Phone/PDA Holders as
Pump/PDM Holders
Making it Stick (or not)
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Antiperspirant
Skin Prep, IV Prep,
Bard wipes
Skin Tac / Tac Away
Mastisol / Detachol
IV3000,Tegaderm
Polyskin, Water proof
sports tape
STR Surgical and
Sports Tape Remover
Sick Days
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Test blood or urine ketones if >300
or >240 twice
Give a shot and change set if
positive
Increase fluid intake
Use of temp basal
Extra tape to site for surgery
Vacations
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10-50% reduction
in dosages
Travel letter and
current dosing
Take along “loaner
pump” and/or
basal insulin &
syringes
More frequent set
changes