Pump Case Study - Joslin Diabetes Center

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Putting Pump Policies Into
Practice- Case Study
Conference Call
Elizabeth Blair, ANP-BC,CDE
Joyce Lekarcyk, RN, CDE
Objectives:
 Able
to assess probable causes of
hypoglycemia and hyperglycemia
 Able to interpret data to make changes in
pump settings
 Able to identify other technologies
available to determine insulin adjustment
Assessment Tools






Assessment should include evaluating the
following:
Total daily dose- % of basal vs. bolus
Evaluating I:C ratio and sensitivity factor
Evaluating basals rates
Trouble shooting, insertion sites, insulin usage,
technique
Glucose records can be used to determine
whether the cause of hyperglycemia or
hypoglycemia is related to basal vs. bolus
Basal vs. Bolus- Tips to decide
When and why does it happen?

Probable causes of
hypoglycemia:
Bolus

Timing of bolus
Stacking
Carb counting vs. estimating
Food choices
Alcohol
Activity
New sites
Basal rate





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

Probable causes of
hyperglycemia:
Bolus

Timing of bolus
Grazing
Carb counting vs. estimating
Food choices
Alcohol
Activity
Set change
Basal rate
Technique vs. compliance



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
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
Case Study





John O
John has had Type 1 diabetes for 30 years
The last 5 years he has been using a
Medtronic insulin Pump 522
Three vessel CABG 9 years ago
Hypoglycemic unawareness
TDD: Basal: 14.6 Bolus: 27 to 36 units
A1c 7.3%
Initial record review
Day 1
12
AM
BG
Carb
grams
Meal
Bolus
High Bolus
Basal Rate .1
3
5
44
.6
6
121
1
7
8
178
9
10
11
12
PM
190
2
156
28
25
5.6
5
2.1
.8
1
2.1
3
4
5
6
123
2.9
7
8
9
84
10
68
25
25
5
5
2.8
.45
1
.4
11
Initial record review
Day 1
12
AM
BG
Carb
grams
Meal
Bolus
High Bolus
Basal Rate .1
3
5
44
.6
6
121
1
7
8
178
9
10
11
12
PM
190
2
156
28
25
5.6
5
2.1
.8
1
2.1
3
4
5
6
123
2.9
7
8
9
84
10
68
25
25
5
5
2.8
.45
1
.4
11
Initial record review
Day 2
BG
Carb
grams
Meal
Bolus
High
Bolus
Basal
Rate
12
AM
114
5
285
3.4
.1
.6
1
6
7
8
9
10
11
12
PM
1
2
3
4
5
6
204
110
147
64
71
22
10
25
21
10
4.4
2
5
3.1
2.0
6.9
2.5
.8
.45
7
8
9
10
77
1
.4
11
Initial record review
DA Y 3
BG
12
AM
3
11
1
93
Carb
grams
Meal
Bolus
High Bolus
Basal Rate .1
.6
5
6
181
1
7
8
9
10 11
12
PM
178
1
2
3
4
5
204
182
26
20
25
23
5.2
4
5
4.6
3.1
.9
4.1
.8
.45
6
7
8
9
10 11
109 70
123
1
.4
.1
Pump Settings

Pump settings: 1:5 ratio SF: 30 Target
glucose: 95
 Basal 12a - 0.1
3a - 0.6
5a – 1.0
6a - 0.8
12p - 0.45
8p - 1.0
10p - 0.4
Your answers
Why?
Your answers

Which pump settings should you
question?
a)
b)
c)
d)
IC ratio and SF
Target glucose
Basal rates
all of the above
Your answers

What pump setting would you
change first?
a)
Recalculate basal rate based on TDD
Recalculate IC ratio and SF
Wait for more trends
Change glucose target
All except for c
b)
c)
d)
e)
Tools to use
Recalculating IC ratios and SF

IC ratio- TDD divided by 450

Sensitivity factor: TDD divided by 1500
Any other way to change ratios?
Adjusting Bolus Rates per Policy
PC-142
If BG is > than target for 2 days at the
same time: increase the IC ratio:
 Example: Change 1:15 to 1:12

If BS is < than for les than target for 2
days at the same time: decrease the
IC ratio:
 Example: Change 1:15 to 1:18

Recalculate basal based on TDD
Possible basal:
Average TDD=49
X .50 = 24.5 divided by
24=1.0 per hour




1500 divided by 49 =SF
of 30
450 divided by 49 =IC
ratio of 9
Compared to current
basal:
14.7 units per day
IC ratio of 1:5
Sensitivity factor of 30
First priority - Prevent the low’s
Initial changes:
I:C Ratio 10-10-9
SF: 40 Target:120
Basal: 12- 0.4
3- 0.6
5- 1.0
6- 0.75
11-0.8
6p-1.0
10p-0.4


Current rates:
1:5 ratio SF: 30
Target glucose: 95
Basal 12a - 0.1
3a - 0.6
5a – 1.0
6a - 0.8
12p - 0.45
8p - 1.0
10p - 0.4
BG records can only tell you so
much! Is there a better way?
First Change: Overnight Basal
Evaluation
Overnight
FAST
BG
Carb grams
Meal Bolus
High Bolus
Basal Rate
12
AM
5
6
7
129
.6
12 AM
3
Lab BG
161
142
8
125
.4
OVERNIGHT
FAST
Carb
grams
Meal Bolus
High Bolus
Basal Rate .4
3
1.0
5
.75
6
9
10
239
213
.
7
8
11
12
PM
1
2
3
4
197
127
47
32
4.7
3.2
9
10
11
1.0
7
8
9
10
12
PM
134
1
2
11
161
1
.4
3
4
5
6
204
268
286
93
25
.6
6
.8
168
2.5
3.7
.75
5
7
8
9
10
164
46
4.4
.6
.8
2.8
1
.4
11
Basal rate change
After reviewing overnight Basal results
would you:
a) Increase the basal rate by 0.1 at 5am
b) Make no change
c) Consider changing supper IC ratio
d) Increase basal from 10 to 2 by 0.1
Morning Fast
MORNING
FAST
5
12
AM
138
BG
Carb grams
Meal Bolus
High Bolus
Basal Rate
6
.4
.6
1.0 .75
7
8
9
10 11
12
PM
1
2
3
4
5
6
7
8
9
10 11
174 176 200 186
.8
1
.4
.4
Morning basal evaluation

a)
b)
c)
d)
What changes would you make after
reviewing the morning basal
evaluations results?
Make no changes and repeat the fast
Increase the basal by 0.1 at 8am
Ask about activity
A and C
Lunch Fast
LUNCH FAST
12
AM
5
6 7
BG
204
Carb grams
Meal Bolus
High Bolus
Basal Rate
38
3.8
2
.4
.6
1.0 .
7
5
8
..85
9
10
11
.8
12
PM
1
2
3
4
5
93
103 121 138 145 160
6
1
7
8
9
10
.4
11
Lunch basal evaluation

a)
b)
c)
d)
What changes would you make after
reviewing the lunch basal evaluation
results?
Make no changes
Increase the basal rate by 0.1 at
noon
Increase the basal rate by 0.1 at 2pm
Increase the basal rate by 0.2 at 2pm
Evaluating Morning Bolus
EVALUATING
MORNING
BOLUS
BG
Carb grams
Meal Bolus
High Bolus
Basal Rate
12
AM
5
6
7
8
119
30
.4
.6
1.0
.85
9
10 11
12
PM
149
132
.8
1
2
.9
3
4
5
6
1
7
8
9
10 11
.4
1
“My latest sugars still need a little
work”
DATE
12
AM
BG
112
Carb grams
Meal Bolus
High Bolus
Basal Rate
.4
DATE
12
AM
Meter BG
82
Carb grams
Meal Bolus
High Bolus
Basal Rate
15
5
6
7
8
9
128
.6
11
139
1.0
5
10
.85
6
7
8
12
PM
1
2
3
88
137
205
188
231
76
2.1
3.8
7
3.5
.8
9
10
11
4
5
6
135
172
205
4.1
2.5
5.1
1
8
9
1
.9
12
PM
7
2
3
360
275
4
5
6
242
203
7
8
10
11
.4
1
9
184
3
8.3
4.3
2
10
11
Your intervention

a)
b)
c)
d)
In order to prevent the glucose spike
after lunch what would you do first?
Ask if his meals have change
Nothing-wait for more trends
Suggest doing a lunch bolus
evaluation
a and c
“I had a cortisone shot and my
sugars are high”
John gave his glucose by phone
 24 hours glucose readings ranged
from 200 to 350 mg/dl
 Infusion set and insulin were changed
 Ketones-small
Your intervention

What Sick Day Management
Guidelines would you give?
a)
50% increase in basal rate for 4
hours
10% of total daily dose via pump
20% of total daily dose via syringe
Either a or b
b)
c)
d)
Lunch bolus evaluation
John ate 30 gms of carbohydrates:
Glucose before lunch was 100
 Glucose 3 hours later was 200

Your intervention

a)
b)
c)
d)
What pump setting change would
you make?
Change I:C to 9 from 10
Inquire about activity and what he
ate
a and b
Increase basal 0.1 at 1 pm
Pumping is less challenging to patients when
there is a team approach and plenty of follow-up!
Stay tuned to submit a final evaluation of
this presentation !
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