Advanced Insulin Pumping(getting your pump to perform its best)

Stephen W. Ponder MD, FAAP, CDEProfessor

Texas Tech Health Sciences Center

Advanced pumping prerequisites

1. Advanced pumping without solid pumping basics is like building a mansion without a foundation!

2. Work towards mastering the art of “glycemic load” combined with your unique responses…know your food!

3. You steer your own course through the choppy waters of tight blood sugar control…it’s all about choices and process.

The “mother of all pump settings” is the

total daily dose! (TDD)

The 5 basic pump settings

1. Basal rate(s)

2. Insulin on board

3. Target BG(s)

4. Insulin to carb ratio

5. Correction factor

1 or more

2-8 hours (3-5)

1 or more (or a range)

1 or more

1 or more

REMEMBER: K.I.S.S.

Reviewing the rates and ratios

Insulin to Carb (I:CHO)

Insulin Sensitivity (correction) factor

Basal rate profile(s)

TDD⁄500

TDD⁄1800

12M – 3AM

3AM – 7AM

7AM – 12M

40-60% of TDD

0.7U/h

1.0U/h

0.85U/h

Example:

Doing an at home pump “pit stop”

Check pump timeDownload/review bolus

history (time?)

Download/review meter and/or log book (time?)

Review basal ratesCheck for bubbles Inspect infusion site

Ponder’s Pumping Principles

I. A pump is no better or worse than the human being attached to it

II. Glycemic variability is the NORM in diabetes: it’s a matter of how much!

III. Age is not a limiting factorIV. A good pump doc is more a

coach (educator) than a prescriber

V. Simple is always a good start

Ponder’s Pumping Principles

VI. Quality diabetes self care is more of a PROCESS than it is an OUTCOME

VII. Hardware and software change: people don’t

VIII. Consistency is a virtueIX. Success is relativeX. Don’t ever be afraid to start

over

Common pump management errors

• Failure to recognize need for changes– Not reviewing BG, A1c

or pump history data– Patient-related errors– Update pump settings

• Failure to provide on-going educational support

Good Control

Inaccurate carb counting Missed boluses Fear of hypoglycemia No BG input from user Lack of diabetes education Outdated pump settings The imprecision inherent in

pump settings

Weak links to good control with the insulin pump

Good Control

Know where the challenges are…

1. Overnights

2. Early mornings

3. Afternoons

4. Missed/skipped boluses

5. Over-bolusing

6. Adolescent “resistance”

7. Toddler hypersensitivity

8. Fix lows first

Know where the challenges are…

1. Overnights

2. Early mornings

3. Afternoons

4. Missed/skipped boluses

5. Over-bolusing

6. Adolescent “resistance”

7. Toddler hypersensitivity

8. Fix lows first

1. ↓ insulin need @ 2-4 AM

2. ↑ insulin need @ 6-9 AM

3. ↓ basal need mid-afternoon

4. More common in ♀ teens

5. More common in ♂ teens

6. Higher basal % in teen years

7. Lower basal % needed

8. Lows beget highs!

~2AM to 4AM is the biologic low point for insulin need

~ 40% of hypoglycemia occurs during sleep! It’s often asymptomatic!

Bre

akfa

st

Lu

nch

Sn

ack

Su

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er

Sn

ack

bolusbolus

bolus

2 -

4 A

M

Bre

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st6

– 9

AM

Sn

ack

0.75U/hr

Basal rates

0.5 U/hr

1.0 U/hr

Midnight

3 AM

6 AM

B A S A L

timetime

Programmed for the “typical” day

Stop Lows FirstBetter control and more stability

• Mild lows cause followup

lows • Small epinephrine release

makes muscles sensitive to insulin

• Can lead to another low as much as 36 hours after the first

• More carbs than usual are needed

Severe lows cause highs

Higher stress hormone release makes glucose rise for 6-10 hrs

Excess carb intake leads to highs

Boluses may be reduced/skipped

More insulin than usual needed

To stop lows, lower the TDD!!!

10 advanced pumping tips1. Basal and bolus self

review/checking

2. Extended boluses

3. Combination boluses

4. The “Sleep bolus”

5. Superbolusing

6. Temporary basal rates

7. Alternate basal profiles

8. Surgery and the pump

9. Bridging the gap

10.Do a pump “pitstop”

. . ..

..

..

..

2 hours150 mg/dl

80 mg/dl

135 mg/dl

glu

cose

0.75 U/hr B A S A L

timetime

94 mg/dl

Testing a basal segment

145 mg/dl

2 hours 2 hours

105 mg/dl

fasting

. . ..

..

.

..

.

..

2 hours155 mg/dl

95 mg/dl

125 mg/dl

glu

cose

0.75 U/hr B A S A L

timetime

60 mg/dl

Bolus for a measured amount of carbs

Testing a bolus

145 mg/dl

215 mg/dl

6

time

0.75 U/hr

Insulin to Carb [I : CHO] ratio

B A S A L I N S U L I N

. . ..

..

.

..

.

..

2 hours

time

180 mg/dl

80 mg/dl

125 mg/dl 150mg/dl

Example: 1 to 10

60 grams CHO / 10

60 / 10 = 6

6

“Acceptable” = “target” +/- 30 mg/dl

glu

cose

bo

lus

CH

O

5

time

0.75 U/hr

“Correction” dose

B A S A L I N S U L I N

. . ..

..

.

..

.

..

2 hours

time

180 mg/dl

80 mg/dl

250 mg/dl

110 mg/dl

Example: 1 to 25

Actual – target / 25

250 – 125 / 25 = 5

5

“Acceptable” = “target” +/- 30 mg/dl

glu

cose

bo

lus

Two week pumper log sheet

(complete the open spots)

Influenced by basal

Influenced by boluses

Checks overnight basal(s)

0.75 U/hr

“Extended” bolus

8 Units

60 minutes

B A S A L

timetime

Best used for grazing-like feeding (e.g., long banquets, receptions, salads, etc…)

Which of the following foods IS NOT a good reason for considering use of the extended/combo bolus feature?

A. Cheese and Pepperoni pizza

B. Cheese enchilada plate

C. Pasta al dente

D. Salad bar

E. Baked potato

0.75 U/hr

Combination bolus

2 hours

4 Units

6 Units

B A S A L

Ideal for patients with gastroparesis (delayed stomach emptying)

Also, excellent for foods high in fat and protein (pizza, mexican food, pastas)

timetime

time

0.75 U/hr

The “Sleep bolus”

B A S A L I N S U L I N

. . ..

.

.

..

.

..

6 hours

time

180 mg/dl

80 mg/dl

Bedtime (10PM) BG: 251 mg/dl

Fasting (7AM) BG: 120mg/dl

5.5 units

glu

cose

bolus

A modified extended bolusFor treating a high bedtime BGCalculate correction doseDeliver it over 5-6 hoursReduces risk of low BG @ 3AM

6

time

1.00 U/hr

Effect of high GI food

B A S A L I N S U L I N

. . ..

..

.

..

.

..

2 hours

time

180 mg/dl

80 mg/dl

125 mg/dl

110mg/dl

Example: 1 to 10

60 grams high GI CHO

60 / 10 = 6

6

Blood sugar “spike”

glu

cose

bo

lus

CH

O

300 mg/dl

5-6 hours

Superbolusing: (i.e., Robbing Peter to pay Paul)

• Taking from basal to add to bolus insulin

• Useful for• high GI foods• large carb loads• faster correction of a

high BG

0.00 U/hr

9

time

1.00 U/hr

“Superbolus”

B A S A L I N S U L I N

. . ..

..

.

..

.

..

2 hours

time

180 mg/dl

80 mg/dl

125 mg/dl

Example: 1 to 10

60 grams high GI CHO

60 / 10 = 6 + 3 =

9

Normal BG change

glu

cose

bo

lus

CH

O

140 mg/dl

9

0.00 U/hr

Superbolus for faster correction

. . ..

..

.

..

.

..

2 hours

180 mg/dl

80 mg/dl

125 mg/dl

glu

cose

0.75 U/hr B A S A L

timetime

60 mg/dl

Exercise or other strenuous activity

Temp basal rates

.

0.95 U/hr

timetime

Alternate basal rate profile examples

W E E K D A Y B A S A L P R O F I L E 1

0.95 U/hr W E E K E N D B A S A L P R O F I L E 2

6 AM 11 AM

1.35 U/hr P R E M E N S T R UA L B A S A L P R O F I L E 3

Surgery and the Pump

If possible, wear the pump. It’s the best way to control blood sugar during the operation, especially for minor procedures (e.g., dental)

If infusion site is in the operating field, simply relocate the site the day before

The anesthesiologist can monitor blood sugar and adjust IV sugar as needed to keep sugar levels under control.

D5 0.45 NS

Peak activity

Duration

NPH (0.3 - 0.4 U/kg)

Aspart or lispro (0.1U/kg)

RULE: insulin action via a pump is short-lived. Rapid-acting injected insulin can serve as a “bridge” while longer acting insulin provides “basal” insulin coverage.

Basal rate

Option 1

2 hours

Duration

Glargine (~basal dose)

Aspart or lispro (0.1 U/kg)

RULE: insulin action via a pump is short-lived. Rapid-acting injected insulin can serve as a “bridge” while longer acting insulin provides “basal” insulin coverage.

Basal rate

Option 2

2 hours