advanced pump management gary scheiner ms, cde integrated diabetes services 333 e. lancaster ave.,...

Advanced Pump Advanced Pump ManagementManagement

Gary Scheiner MS, CDEGary Scheiner MS, CDE

Integrated Diabetes ServicesIntegrated Diabetes Services333 E. Lancaster Ave., Suite 204333 E. Lancaster Ave., Suite 204

Wynnewood, PA 19096Wynnewood, PA 19096(877) 735-3648(877) 735-3648(610) 642-6055(610) 642-6055

www.integrateddiabetes.comwww.integrateddiabetes.comgary@[email protected]

The Pump Club of Greater Philadelphia

Advanced Pump Advanced Pump ManagementManagement

• Basal Insulin RegulationBasal Insulin Regulation

• Bolus RegulationBolus Regulation

• Physical Activity AdjustmentPhysical Activity Adjustment

• DKA PreventionDKA Prevention

• Temporary Basal RatesTemporary Basal Rates

• Prolonged BolusesProlonged Boluses

• Alternate Basal PatternsAlternate Basal Patterns


Basal Insulin Basal Insulin RegulationRegulation


• Basal Insulin’s One And Only Job Is To Basal Insulin’s One And Only Job Is To

Hold Blood Glucose Levels Hold Blood Glucose Levels SteadySteady In the In the

Absence of Confounding InfluencesAbsence of Confounding Influences**

* Food, Exercise, Bolus Insulin, Unusual Hormonal * Food, Exercise, Bolus Insulin, Unusual Hormonal Conditions (illness, rebounds, menstruation)Conditions (illness, rebounds, menstruation)



Conditions for Testing Basal Rates:Conditions for Testing Basal Rates:• No food or bolus for at least 4 hrs priorNo food or bolus for at least 4 hrs prior

• Last meal/snack low in fatLast meal/snack low in fat

• No food or bolus during test phase (water/diet drinks OK)No food or bolus during test phase (water/diet drinks OK)

• BG above 80, below 250 throughoutBG above 80, below 250 throughout

• No lows for previous 12 hrsNo lows for previous 12 hrs

• Stay connected, no stopping/suspendingStay connected, no stopping/suspending

• Exercise OK up until test phase (if usually performed)Exercise OK up until test phase (if usually performed)

• No heavy activity during test phaseNo heavy activity during test phase

• Do not run test if sick or just prior to/start of periodDo not run test if sick or just prior to/start of period



TestTest Last Meal / Last Meal / Bolus ByBolus By

Check BG atCheck BG at May Eat / May Eat / Bolus Again atBolus Again at

OvernightOvernight 6pm (skip 6pm (skip night snack)night snack)

10pm, 1am, 4am, 10pm, 1am, 4am, 7am7am

7am7am

MorningMorning 3am (skip 3am (skip breakfast)breakfast)

7am, 9am, 11am, 7am, 9am, 11am, 12noon12noon

12 noon12 noon

AfternoonAfternoon 8am (skip 8am (skip lunch)lunch)

12 noon, 2pm, 4pm, 12 noon, 2pm, 4pm, 5pm5pm

5pm5pm

EveningEvening 1pm (have 1pm (have late dinner)late dinner)

5pm, 7pm, 9pm, 5pm, 7pm, 9pm, 10pm10pm

10pm10pm

Sample Basal Testing Schedule



Average basal profiles*

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

12

-1a

1-2

a2

-3a

3-4

a4

-5a

5-6

a6

-7a

7-8

a8

-9a

9-1

0a

10

-11

a1

1-1

2p

12

-1p

1-2

p2

-3p

3-4

p4

-5p

5-6

p6

-7p

7-8

p8

-9p

9-1

0p

10

-11

p1

1-1

2a

units

/hou

r

age 11-20

age 21-60

age 3-10

age >60

* Diabetes Research & Clinical Practice (2005) 14-21.



Example 1: Sara Smiley

• Currently:Currently: .30 3am-9am, .30 3am-9am, .25 9am-3am.25 9am-3am

• Skipped BreakfastSkipped Breakfast

• BG results:BG results:

6am 1096am 109

8am 2018am 201

10am 23010am 230

12pm 22412pm 224

Interpretation:Sharp rise 6am-8am

Modest Rise 8am-10am

Stable 10am-12 noon

Adjustments: Basal by .1 5a-7a Basal by .05 7a-9a

Repeat test from 6a-12p

Bolus Insulin Bolus Insulin RegulationRegulation


I:C Ratios:I:C Ratios:

• The correct ratio should match pre-meal BG 3-4 The correct ratio should match pre-meal BG 3-4 hours (not 2!) after eatinghours (not 2!) after eating

• I:C Ratio often varies from meal to mealI:C Ratio often varies from meal to meal

(bkfst dose > lunch & dinner)(bkfst dose > lunch & dinner)

Bolus Insulin Bolus Insulin RegulationRegulation


Correction Boluses:Correction Boluses:• 1500-Rule (aggressive)1500-Rule (aggressive)

(Total Daily Ins.)/1500(Total Daily Ins.)/1500

• 1800-Rule (conservative)1800-Rule (conservative)

(Total Daily Ins.)/1800(Total Daily Ins.)/1800

• May vary day vs. nightMay vary day vs. night

(nighttime often 50% more than day)(nighttime often 50% more than day)

Physical Activity Physical Activity AdjustmentsAdjustments


Activity Within 2 Hrs Activity Within 2 Hrs After MealAfter Meal

Activity Before or Activity Before or Between MealsBetween Meals

Short DurationShort Duration(<90 Minutes)(<90 Minutes)

Mealtime BolusMealtime Bolus Snack Prior to Activity*Snack Prior to Activity*

Long Duration (>90 Long Duration (>90 Minutes)Minutes)

Mealtime BolusMealtime Bolus Basal RateBasal RateSnack hourlySnack hourly

Basal RateBasal RateSnack hourlySnack hourly



Meal BolusMeal Bolus Adjustment*Adjustment*

Low Intensity Cardio Low Intensity Cardio 25% 25%

Mod. Intensity Cardio Mod. Intensity Cardio 33% 33%

High Intensity Cardio High Intensity Cardio 50% 50%

Competitive/Anaerobic Competitive/Anaerobic ??????

* If activity is after meal* If activity is after meal

Basal Basal Adjustment**Adjustment**

Basal rate 50%Basal rate 50%

Start basal reduction 1 hr Start basal reduction 1 hr pre-activitypre-activity

** For activities lasting > ** For activities lasting > 90 Min.90 Min.



• Snacking to prevent low (examples)Snacking to prevent low (examples)

Carbohydrate Replacement Per 60 Minutes of Activity

50 lbs 100 lbs 150 lbs 200 lbs 250 lbs

Skating 7-10g 14-20g 20-30g 28-40g 35-50g

Gymnastics 8-12g 17-23g 25-35g 34-46g 42-57g

Soccer 13-17g 27-33g 40-50g 54-66g 67-82g



Watch Out for D’OH!Watch Out for D’OH!(Delayed Onset Hypoglycemia)(Delayed Onset Hypoglycemia)

Following high-intensity Following high-intensity exerciseexercise

Following extended- Following extended- duration activityduration activity

May occur up to 24 hours May occur up to 24 hours afterwardsafterwards

Extra snacks or reduction Extra snacks or reduction in basal insulin may be in basal insulin may be necessarynecessary



OK To Disconnect Up To OK To Disconnect Up To 11 Hour w/ Activity Hour w/ Activity

Disconnection for 2 hours of exercise:Additive basal pulse action



Alternatives to Disconnection:Alternatives to Disconnection:

Wear It! (Sport Pack, Fanny Pack, Backpack Harness)

Re-Connect hourly & bolus 50% of missed basal rate

DKA DKA PreventionPrevention


Normal Cellular MetabolismNormal Cellular Metabolism

(Body Cell)

Insulin

G

G

Fatty Acid

K Energy+



Metabolism Metabolism With With Insulin Insulin DeficiencyDeficiency

K

(Body Cell)

Insulin

G

Fatty Acid

Energy

K

K K KBlood StreamKidney

To Urine

K

K+

+

+ + +

+



Progression Progression to DKAto DKA

(Body Cell)

Blood Stream Kidney

To Urine

Fatty Acid

Fatty Acid

Fatty Acid

K

K

K

K

K

K

KK K

K

Liver

G

G

G

GG G GG

G

K

+ +

+ + +

+

+

++

++

ENERGY

Higher B.G.

+ More Ketones

+ Dehydration

**KETOACIDOSIS**



Causes of insulin deficiency in Pump TherapyCauses of insulin deficiency in Pump Therapy

Malabsorption (site problems)Malabsorption (site problems)

Insulin SpoilageInsulin Spoilage

Tubing or infusion set clogsTubing or infusion set clogs

Leaks where the cartridge connects to the tubingLeaks where the cartridge connects to the tubing

Air pockets in the tubingAir pockets in the tubing

Dislodgement of the canula from beneath the skinDislodgement of the canula from beneath the skin

Improper or insufficient primingImproper or insufficient priming

Extended pump suspension or disconnectionExtended pump suspension or disconnection



Unexplained High Blood Sugar

Check for Ketones

Ketones Ketones Negative Positive

Bolus w/Pump BS Doesn’t Drop 1. Shot w/Syringe

BS Drops 2. Drink Water 3. Change Out Pump

OK

Temporary Temporary Basal RatesBasal Rates


• Basal Insulin Should Hold BG Basal Insulin Should Hold BG Steady Under Normal Conditions.Steady Under Normal Conditions.

• How Often Is Life Under “Normal How Often Is Life Under “Normal Conditions”?Conditions”?



• High-Fat FoodHigh-Fat Food

DurationDuration AdjustmentAdjustment NotesNotes

8:008:00 +60%+60% Start After Start After MealMeal



• IllnessIllness


24:0024:00 +80%+80% Repeat as Repeat as NeededNeeded



• Predictable Predictable StressStress


3:003:00 +80%+80% Set 1-2 Set 1-2 Hours PriorHours Prior



• Extended Extended InactivityInactivity


Varies Varies (>3 hrs)(>3 hrs)

+40%+40% Great for Great for long trips!long trips!



• Menstrual Menstrual CyclesCycles


12:0012:00 +50% (pre)+50% (pre) Start at nightStart at night

12:0012:00 -30% (post)-30% (post) Start at nightStart at night



• Prolonged Prolonged ActivityActivity


Minimum Minimum 2 hrs.2 hrs.

-50%-50% Start 1-2 Start 1-2 hours priorhours prior



• AlcoholAlcohol


2 hrs per 2 hrs per drinkdrink

-40%-40% Begin after Begin after drinkingdrinking

Prolonged Prolonged BolusesBoluses


• DescriptionDescription

Normal/Standard Boluses are delivered within a Normal/Standard Boluses are delivered within a few minutes; peak is approx. 1 hr, duration few minutes; peak is approx. 1 hr, duration approx. 4 hoursapprox. 4 hours

Prolonged boluses are delivered over a period Prolonged boluses are delivered over a period of a couple of hours; peak is delayed/blunted of a couple of hours; peak is delayed/blunted and duration is extended.and duration is extended.



• PurposePurpose

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

0 1 2 3 4 5

Rapid-DigestingMeal/SnackSlow-DigestingMeal/Snack



• ApplicationsApplications

Very Large PortionsVery Large Portions

Low-Glycemic-Index FoodsLow-Glycemic-Index Foods

Meals/Snacks that take a long time Meals/Snacks that take a long time to consumeto consume



Options for slow-digesting food:Options for slow-digesting food:

Normal BolusNormal Bolus

0 1 2 3 4 5

BG Rise

Insulin




Square/Extended BolusSquare/Extended Bolus

0 1 2 3 4 5

BG Rise

Insulin




Dual/Combination BolusDual/Combination Bolus

0 1 2 3 4 5

BG Rise

Insulin

AlternateAlternateBasal PatternsBasal Patterns


• Called Called Pattern A/BPattern A/B (Medtronic), (Medtronic), Prog 2-4Prog 2-4 (Animas), (Animas), Pattern 1-4Pattern 1-4 (Deltec)(Deltec)

• Useful when basal changes are Useful when basal changes are needed for several days (or more) needed for several days (or more) in successionin succession

AlternateAlternateBasal PatternsBasal Patterns


Menstrual cycle phasesMenstrual cycle phases

Extended illnessExtended illness

Recovery from surgeryRecovery from surgery

Periodic use of steroid medicationsPeriodic use of steroid medications

Seasonal sportsSeasonal sports

Off-day vs. work/school-dayOff-day vs. work/school-day

Extended travelExtended travel

Climate changesClimate changes

Potential Uses:Potential Uses:

The Ultimate The Ultimate Pump ChallengePump Challenge


advanced pump management gary scheiner ms, cde integrated diabetes services 333 e. lancaster ave.,...

Documents

basal rate slide

basal reduction

basal insulin regulation

meal activity

g slide

day slide

testing basal rates

minutes of activity