Advanced Pumping. Objectives: Identify situations to utilize temporary basal rate in pump therapy...
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Transcript of Advanced Pumping. Objectives: Identify situations to utilize temporary basal rate in pump therapy...
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