Pumping
How Do I Start?
John Walsh, P.A.
Author: Pumping Insulin, Using Insulin
(619) 497-0900 www.diabetesnet.com
What We’ll Cover
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Introduction to pumps
Advantages of pumping
Am I a candidate?
How to choose a pump and infusion set
What is needed to start
Importance of data
Site preparation
Troubleshooting
Formulas that help
Smart features
Where Pumps Began
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Started ~1978 with conversion of
portable chemotherapy pumps to
delivery of insulin
The Autosyringe AS2C and Harvard
Apparatus Mill Hill Infuser were first
Single basal, no memory
50 ml syringe on pump exterior
Required dilution of insulin
to U-36 or U-18
1976 Biostator (top) and 1978 Autosyringe AS2C –>
The Basal-Bolus Concept
Advantages
 Flexibility
in meal timing & size
 Eat when you want to
 Faster adjustment of
insulin for exercise
 Family activities are no longer tied to
one person’s needs
 Easier handling of illness, travel, or
camping
Advantages
More Consistent Insulin Action

The same dose of NPH
insulin given to the same
individual varies by 25%
from day to day
 Order of variablility:
NPH > Lente > Lantus >
Detemir
 A pump has less variable
insulin delivery at 3%
Advantages
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Precise doses, as small
as 0.025 u, can be given
 Manages the Dawn
Phenomenon
 Improves control during
growth spurts and
adolescence
 Reminders
Who Is A
Good Pump Candidate?
Why Choose A Pump?
 A freer
lifestyle
 Easier dose determinations
 Improved blood sugars
 Flexibility in meal timing and size
 Ability to exercise without losing control
 Peace of mind
When To Consider A Pump
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More than 3 injections per day
Tired of multiple injections
Frequent or severe hypoglycemia
Hypoglycemia unawareness
Elevated A1c
DKA or ER/hospital admission
Strong Dawn Phenomenon
Require small, precise doses
Less risk of complications
Insulin Pump
Pro
 Less work
 Simplified insulin dosing
 Precise delivery
 Greater impact in those
with highest starting A1c
 Slightly less insulin use
per day
Con
 More DKA
 More severe
hypoglycemia
 A1c levels and
frequency of DKA &
hypoglycemia are
similar to ICT
What It Takes To Succeed
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A personal desire for better control
Willing to adjust insulin doses to carb
count, test results, and activity
Willing to monitor at least 4 times a day
Willing to keep an accurate record of
BGs, boluses, and carb counts
Committed to solve problems and adapt
lifestyle as needed
Success For Kids On Pumps
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Supervision is required: kids BEGIN to
develop self care skills at about age 10
Family support is essential: an adult who can
go to school, etc.
Communication with a health care team that is
committed to pumps
Adequate insurance and financial resources
Assistance and support from teachers,
friends, babysitters, grandparents, siblings
Features For Infants & Toddlers
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Little ones are ideal pump candidates if the
parents are
Delay or split boluses for fussy eaters
Small, user-friendly pumps offer precise
dosing (0.05, 0.025, or 0.01 unit increments)
Lock out
Worn between shoulder blades
If a toddler likes to remove the
infusion set, let them know what
comes out must go right back in
Help For Kids & Teens
 Growth
spurts
 Dawn Phenomenon
 Easy coverage of snacks
 TDD and bolus history can be checked
to ensure consistent dosing
 Faster adjustment of basals and boluses
for changes in activity, etc
Special Teen Concerns
 Dating
 Wearing,
sharing
 Alcohol
 Eating
disorders
 Fast foods
 Fabrication
 Sleeping-in
Personal Effort
Those who expect a pump
to manage their diabetes
for them will fail to
optimize their own
therapy.
Learn how to adjust your basals and boluses
for an excellent A1c!
First Steps Toward A Pump
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Keep detailed records
 Consider your (and your child’s) motivation
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Peer group, acceptance issues, family support
Look at available pumps
 Which pump(s) does your insurance cover?
 Talk with your doctor about a prescription
 Visit a dietician to learn carb counting
What To Learn
 How
your pump works
 How to count carbs
 How to interpret BG results
and see BG patterns
 When to increase and
decrease basals and boluses
 How to adjust for high GI foods, extra
activity
How To
Choose A Pump
Pump Companies
Who sell or plan to sell
pumps in the US:
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Animas R1200
Dana Diabecare III
Deltec Cozmo
Medtronic Paradigm
Nipro Amigo
Roche/Disetronic
Visit www.diabetesnet.com/diabetes_technology/
Things To Consider
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Look, feel, color
Features: reminders, child block, waterproofing
Size of basal and bolus increments
Infusion set choices
Safety and reliability
Customer support
History
Ease of data analysis
Add-ons: meters, covers, cases
Today’s Smart Pumps
 Easy
dose calculations with Carb Factor
and Correction Factor
 Precise insulin dosing (0.05 units or better)
to allow basal rates to be set up for Dawn
Phenomenon, etc.
 Tracks BOB to avoid insulin stacking
 Reminders
Today’s Pumps
 When
control is poor or varies greatly on
one of today’s pumps, the pump settings
are incorrect.
 Test and reset basal rates, carb and
correction factors until you have good
control.
 Garbage in…..
How To Choose
An Infusion Set
Infusion Sets
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Straight-In Teflon: Cleo, Inset, Ultraflex, Quik-Set
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Angled Teflon (Comfort, Tender, Easy, Silhouette):
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Easier to insert, variety of depths (6, 8, 9 mm)
Fewer failures
Insertion site is visible
Longer is more secure
Adjust angle to reach fat
Metal needles (Rapid-D or bent needle)
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As comfortable and often more reliable
Very short, multi-needle infusion sets expected soon
Infusion Sets And Inserters
Disetronic Rapid-D
Smith’s Medical Cleo
Medtronic Sil-serter
Animas Inset
Quik-serter
Site Supplies
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Emla cream (Rx, 30 min wait) or ice cube
Set inserter: Cleo and Inset are self-contained,
ezSerter, Quick-Serter, Sil-Serter, Sof-Serter
Adhesive: IV-3000, Hypafix, Tegaderm
Stickies: Skin Tac-H, Skin Prep
Tape: Micropore, Durapore,
Band-Aid Blister Relief (wicking)
Sweating aid: Mastisol Spray
(Detachol for removal), Skin Tac,
Tincture of Benzoin, Skin Prep
Adhesive removal: Uni-Solve, Allkare
School Supplies
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Meter, lancets, test strips
Glucagon, glucose tablets, or
crackers for lows
Spare insulin, syringes or insulin pen
Spare infusion set and pump batteries
Ketostix or Precision Xtra to test for ketones
Information card with insulin-to-carb ratio,
formula for corrections
Telephone numbers of parents, health care
providers, and pump manufacturer's help line
How To Start
Starting On A Pump
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Everyone is nervous
 Read, read, read
• Pumping Insulin, Kids Insulin Pumps And You
(Animas), www.childrenwithdiabetes.com,
www.pumps4kids.ca, etc, etc
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Do lots of recording before and after start
 Start to play with pump as soon as it arrives
 Saline practice helps
 Get telephone contacts: MD, CDE, pump
company, pump rep, other parents
Helpful Attitudes And Habits
 Be
blatant about your diabetes
 A pump is a tool, not a cure
 Take a bolus for every bite
 Change site as directed
 Look for a solution for every problem
 Write down a reason for every low and high
 Test often
John’s Pump Rules
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Total Daily Dose = weight in lbs / 4
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Basal Dose = 50% to 60% of TDD
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Carb Factor = 500 / TDD
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Correction Factor = 2000 / TDD
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BG target = 90 to 120 mg/dl
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Basal target = +/- 30 mg/dl
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BOB = 20% per hour
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Correction boluses = < 8% of TDD
J Walsh and R Roberts: Pumping Insulin, 2005
Starting Insulin Doses
J Walsh and R Roberts: Pumping Insulin, 2005
Carb Counting And Recording
As Ways To Lower The A1c
Steps For A Better A1c
Carb counting – 0.6%
 Givivg boluses based on an accurate carb count
– 0.3%
 Recording test results, carb intake, insulin
doses, & activity – 0.5%
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Monitoring often – 0.5-2.0%
 Bolusing often – 0.5-2.0%
 Contacting your doctor or adjusting your own
doses when you encounter unwanted BGs
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Carb Counting
 Allows
precise matching of carbs with
boluses
 Glycemic index, saturated fat, and high
protein all play a role, but grams of carb is
what controls the blood sugar after a meal
 Easy!
Where Carbs Come From
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fruit/fruit juice
breads/bagels
cereals
crackers
1 gram of carb
grains
raises the BG
muffins
4 to 7 points!
rice
potatoes/yams
vegetables
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dessert/cookies/cake/pie
ice cream/frozen dessert
sweetened beverages
milk/yogurt (not cheese)
beer/wine
honey/syrup/molasses
jams/jellys/preserves
-ose foods like sucrose
(table sugar)
How To Count Carbs
 Food
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labels
Check portion size
 Books
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Dr’s Pocket Guide, Health Cheques
 A gram
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scale plus carb factors
Carb factors are available in Pumping
Insulin and are built into scales like the
Salter computer gram scale
Blood Sugar Testing – 1921
Blood Sugar Testing – 2004
Blood Sugar Testing – 2004
“I just don't write down (log) anything. I hate to take
the time to do it. I'd rather have a machine talk for
me. I think it revolves around partial general laziness,
as well as the constant reminder of being different
from everyone else. I know other diabetics who won't
even test when they're out with friends. They hate
….”
The Artiste 6/28/04
Charting Improves Control
Smart Charts
 Needed
to solve
problems
 Basis for better
diabetes health care
 ~0.5% drop in A1c
Blood sugar, insulin, food, activity, stress
Better Charts, Better A1c
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Charts
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Software
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My Other CheckBook
Meter companies
Internet: myhealthchannel.com
Pump Control Software
Meters, PDAs & Pumps
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Pump: Deltec, Disetronic, Animas, Medtronic
Meter: BD, Therasense, Lifescan, Boerhinger
Analyze Carb Boluses
1. Count carbs
2. Give carb bolus
3. Eat
4. Record BGs
5. Analyze BGs
6. Balance better next time
Match Your Carbs With Boluses
for HALF the day’s control!
 Keeps blood sugar normal after meals
 Requires accurate carb counting and an
accurate carb factor
 500 Rule provides a close estimate of
carb factor if the TDD is accurate
 Accounts
500 Rule To Find Carb Factor
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Gives grams of carb covered by one unit of
Humalog or Novolog
 500 / TDD = grams of carb per unit of insulin
 Example:
 Person’s TDD = 50 units
 500/50 = 10 grams of carb covered by
1 unit of Humalog or Novolog
 Postmeal readings stay normal!
2000 Rule To Find Correction Factor
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Gives how far your blood glucose is likely to fall per
unit of insulin over 5 hours
 2000 / TDD = # mg/dl your BG will fall per unit
Example:
 Person’s TDD = 25 units
 2000/25 = an 80 mg/dl drop per unit of H or Nov
Adapted from 1500 Rule by Dr. Paul Davidson, Atlanta, GA
2000 Rule
Total Daily Dose
20 units
25 units
30 units
35 units
40 units
50 units
60 units
75 units
Point drop per unit
90 pts
72 pts
1600, 1800, 2000,
60 pts
or 2200 may be
divided by TDD to
51 pts
get point drop per
45 pts
unit
36 pts
30 pts
24 pts
1800 provides a good average --- 1600 Rule is more
aggressive and gives more insulin, while a 2000 or 2200
Rule gives less insulin
New Devices
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Data storage and download
Easy recording of BGs,
insulin, carbs, activity
Automatic carb counting
Pattern recognition
Insulin dose guidance
Data analysis to improve control
Feedback that encourages use
Pump — Meter Combos
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CozMonitor from Deltec
and Therasense
Disetronic and Roche
Medtronic 512 and BD
Paradigm Link
Animas and Lifescan
Dana Diabecare III and
Dana meter
Troubleshooting
Most Pump Problems Occur In
First
 First
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week
month
First 6 months
Problems are most likely when
unexpected or inconvenient
Occasional Pump Problems
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Setup tips
 Leaks
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Allergies
 Bleeding
O-rings
Hub
Line
Clogs
 Site infections
and abscesses
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onto skin
inside needle
under skin
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Pump bumps
 Hypertrophy
 DKA
Some frustration at times is normal!
Set And Site Issues
 Dislodged
infusion set
 Tunnelling
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Rapid-D and slanted Teflon sets
work better for mobile kids
Metal may be better than teflon
 Infection
 Hematoma
Site Preparation
 Prevents
pump bumps, infection, and
abscess
 Steps
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Wash the hands
Sterilize the skin – IV Prep
Use bio-occlusive adhesive – IV 3000
Insert the set
Use safety tape
Will Your Pump Alarm?
Low battery
Mechanical problem
Empty reservoir
Clog
Forgotten bolus
Leak
Bleeding
Bad programming
Dislodged infusion set
Yes
Yes
Yes
Yes
Yes
No
No
No
No
How To Check Mechanical Problems
Check from
skin to pump:
Skin and site
Infusion set
Connection
Line
Hub
Reservoir
Pump
High BG Checklist
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See a leak or smell insulin?
Infusion set in place?
Was infusion set primed?
Are connections at hub and O-rings tight?
Bubbles in the tubing? One inch = a half unit
Clog in line?
Alarms? Errors?
If no cause is found, replace everything!
Check Ketones Early
 Test
for all BGs over 300
 Always test when nauseous
 Test urine with Ketodiastix
 Test blood with Precision Xtra meter
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Earlier detection
No need to collect urine
Keep currently dated strips available
Go to ER at 1st sign of vomiting!
More Insulin For
Unexplained High BGs
 When
a blood glucose test is unexpectedly
high, the correction bolus needed to lower
this will be much higher than normally
required
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Loss of basal insulin delivery for several hours
Insulin resistance from length of
hyperglycemia
Insulin resistance from presence of ketones
Conclusion
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A pump offers the latest
technology for precise insulin
delivery
 Requires commitment and
responsibility
 Benefits include more flexibility,
less hypoglycemia, improved
control, and a longer, healthier
lifespan
 Make the commitment and start
pumping!
Questions
???