Advanced Pumping

Objectives:• Identify situations to utilize temporary basal

rate in pump therapy patients.• Identify examples of when to use

combination and extended bolus in pump therapy patients.

• Verbalize understanding of the insulin on board feature available in current insulin infusion pumps.

• Identify sick day and DKA clinical management guidelines for treatment

Activity

• In table teams take 2 minutes to discuss what a temporary basal is?

• Come up with 3-5 reasons you might use one and write them on the flip chart.

Temporary Basal Rate

• Allows patient to increase or decrease basal rate for a specific period of time based on percent change or units/hr.

– Example:• 50% reduction for 2 hours• 20% increase for 4 hours

Clinical Indications for Use of a Temporary Basal Rate

• Illness or infection• Change in normal

routine– Travel– Work

• Medications– Steriods

• Stress– Holidays– Exams

• Exercise

Temporary Basal Rate and Exercise

• With multiple daily injections (MDI), the patient must snack or adjust the rapid or long-acting insulin

• With pump therapy, a temporary basal change allows the patient to immediately adjust the amount of insulin being infused

Education for Temporary Basal Use

• Check BG frequently to evaluate temporary basal effectiveness

• Start conservatively with a decrease or increase of 10-20%

• Ability to stop temporary basal at anytime

Evaluating Effectiveness of Temporary Basal Rate

– Absence of hypoglycemia/hyperglycemia during exercise

– Absence of nocturnal or post-exercise hypoglycemia

– Decrease in extra snacking to prevent hypoglycemia

– May need to increase or decrease percentage change

Activity

• In table teams take 2 minutes to discuss what is an extended bolus? What is a Combo bolus?

• Come up with 3-5 reasons you might use would use them.

Extended Bolus

• Bolus extended over a designated period of time

• Elements of extended bolus– Dosage– Duration

Example• 4 units delivered over 2 hours• 6.5 units delivered over 4 hours

Combo Bolus• A portion of bolus is delivered immediately

(normal) and a portion is extended over a designated period of time (combo)

• Example: 25/75 split using 4 unit bolus would deliver… – Normal (1 unit)

• To cover portion of CHO or high BG– Extended (3 units)

• To cover high fat bolus or grazing at meals

Clinical Indications for Extended or Combo Bolus• High post-prandial BG’s despite accurate

CHO counting• Hypoglycemia immediately following meal• Grazing, extended eating

– Buffets– Holiday Meals– Parties– Movies

Clinical Indications for Extended or Combo Bolus• Gastroparesis• Slow eaters, such as young children• Large bolus dosage

– May prevent depot of insulin at injection site• Nutrient composition of meal

– High fat– Low glycemic foods– High protein

Evaluating the Effectiveness of an Extended or Combo Bolus• Check BG at 2, 4, 6 & 8 hours after meal• If BG remains in target bolus was

successful• If BG goes low or rises more than 40-80

mg/dL combo bolus needs to adjusted, consider:– Percent split– Dose– Duration

Foods Effect on Blood Sugar: Protein

• Rate of digestion and conversion to glucose depends on state of insulinization and glycemic control

• BG effect difficult to predict– Up to 50-60% can be converted to glucose

Foods Effect on Blood Sugar: Fat

• Effects on BG– Delayed stomach emptying– Decreased insulin sensitivity– Increased insulin resistance– May last for hours after eating

• Minimal fat actually converted to glucose (<10%)

• Individual’s response needs to evaluated

Insulin on Board (IOB)

• After bolus is delivered, IOB tracks bolus insulin still active

• Customizable IOB from 1.5 hrs - 6.5 hrs• May decrease risk of stacking insulin

– Potential for less hypoglycemia

What is the effect of illness on BG?

• Typically BG is elevated during illness– Liver Glucose release increases– Cells less sensitive to insulin

– May have low BG instead• Vomiting • Diarrhea

Activity

• In table teams, take 3 minutes to discuss what causes DKA?

• What are you currently doing in your practice – to prevent and or treat DKA?

• Write current practice guidelines on the flip chart

Causes of Diabetic Ketoacidosis - DKA

• Inadequate or missed insulin dose• Illness• Infections• Stress• Infusion set or site issue• Dehydration

Insulin Pumpers and DKA

• Insulin Pumpers are at a higher risk for DKA

• Only use rapid acting insulin• BG can start to rise within 60-90 minutes

of interrupted insulin delivery • Lack of immediate or long-acting insulin

Problem Solving

• Check for Ketones – early detection of interrupted insulin delivery

• Check tubing for bubbles• Assess infusion site for placement, kinks,

disconnection• Cartridge – insulin available, cracks

Prevention of DKA

• Check your BG at least 4 times a day• For "unexplained” BG > 250mg/dl or

higher -- Check ketones• Take correction bolus by syringe• Change your insulin set and site

– Disconnect from the body before priming• Drink plenty of fluids

Activity

• In table teams, take 3 minutes to discuss your sick day management plans

• List plan on flip chart

Sick Day Plan To Include…

• When and who to call• Frequency of BG testing• Frequency of Ketone testing

– Blood vs Urine testing• Use of a temp basal, duration of setting• Recommendations for vomiting or diarrhea

– What to eat, what if you have given insulin and then vomit.

– Possible use of Glucagon for vomiting induced hypoglycemia