n.insulin-pumps.pdf - services.nhslothian.scot · INSULIN PUMPS PAGE 1 Introduction to Insulin Pump...

INSULIN PUMPS PAGE 1

Introduction to Insulin Pump Therapy

What is an insulin pump and how does it work?

• Aninsulinpumpisasmallelectronicdevicewhichprovidesacontinuousinfusionofveryfastactinginsulin(NovorapidorHumalog)intothesubcutaneoustissue(undertheskin).Itisdesignedtodeliverinsulininawaymoresimilartothepancreasofapersonwithoutdiabetes,thaninsulininjections.

• Thepumpisprogrammableandthesettingscanbechangedifrequiredbyactivatingtheon-screenmenus(patients/parentsaretrainedhowtochangethesettings).

• Insulinisdeliveredthroughaninfusionsetfromthepump,andashortplasticcannulawhichischangedevery2-3daysusinganeedleinsertionset(seethepicturebelow).

• AllpatientsrequireacontinuousinfusionofNovorapidorHumalogwhichactasbasal(orbackground)insulinandtheremaybeseveraldifferentbasalratesettingsoverthecourseoftheday.

• Insulinbolusesarerequired,inadditiontothebasalinsulin,whencarbohydrate-containingfoods/drinksareconsumed.Thebolusisgiventhroughthepump,andthesettingsfortheamountofinsulinrequiredforcarbohydratearepre-programmedintothepump.

• Aninsulinbolusisalsorequiredwhenthebloodglucosereadingishighandtheamountofinsulinrequired(correctionfactor)isprogrammedintothepump.

Who is eligible for insulin pump therapy?

a) Foradults and children 12 years and olderthereasonsforrequiringapumpare:

• IfattemptstoreachtargethaemoglobinA1c(HbA1c)levelswithmultipledailyinjectionsresultinthepersonhaving‘disablinghypoglycaemia’.

• IfHbA1clevelshaveremainedhigh,above70mmol/mol,withmultipledailyinjectionsdespitethepersonand/ortheircarercarefullytryingtomanagetheirdiabetes.

b) Forchildren aged less than 12 years,pumptherapyisrecommendedasapossibletreatmentforallchildren.TheNICEguidelinesadvisethatchildrenwhouseinsulinpumptherapyshouldhaveatrialofmultipledailyinjectionswhentheyarebetweentheageof12and18years.

What does starting on insulin pump therapy involve?

Startinganinsulinpumprequiresabigcommitmentandtakesmoretimeandeffortthanmanagingdiabeteswithinjections.Ifyouputinthetimeandeffortitcanallowflexibilityandgoodbloodglucosecontrol.Itisnotaneasyoption!

The commitment includes:

• Frequentbloodglucosetesting(minimumof8testsperday).

• Keepingadailywrittendiaryofbloodglucoseresultsandevents.

• Veryaccuratecarbohydratecounting.

• Regularcommunicationwiththediabetesteamandclinicattendance.

IftheHbA1cbeforestartingpumptherapyisabove60mmol/mol,adropby7mmol/molshouldbeexpected.Thisneedstobemaintained.

What happens if I become/my child becomes unwell when on insulin pump therapy?

Itisvitaltounderstandtheincreasedriskofdevelopingdiabeticketoacidosiswhenusinginsulinpumptherapy,andbeabletomanagesickdaysappropriately.Theusual24houradvicelinewillnotbeabletoofferadviceforadjustmentofpumpsettings.Itmaybenecessaryinthesecircumstancestoreturntoinsulininjections.Thismaybethecaseifadmissiontohospitalisrequiredduetoillnesswithhighbloodglucosereadingsandhighbloodketones.


The insulin given through the pump is very fast acting insulin, therefore progression to ketoacidosis can occur within four hours if you/your child are not receiving insulin from the pump.


What other equipment is required?

Acomputerisrequiredtodownloadpumpdata,toreviewbloodglucosereadingsandpumpsettings.Thesedownloadsareemailedtothediabetesteambeforeclinics.

What happens if the insulin pump is damaged?

Youshouldinsurethepumponyourhomeinsurancepolicy.Inaddition,thereisacompanywarranty.

How long would it take to start insulin pump therapy?

Theclinicalneedandassessmentofsuitabilitywillbethedecidingfactorsforprogressingthroughtheprepumpprocess.Ifitisagreedthatapatientneedspumptherapythenanassessmentofpriorityisrequired.Anurgentrequirement,e.g.diabetesinababy,willtakepriority.

Thereisawaitinglistforinsulinpumptherapy.Peoplearestartedonpumpsingroupsoftwoorthree,dependingontheirage.Thediabetesteamcangiveyouguidanceastohowlongyouwouldbeexpectedtowaitforaninsulinpump.

What happens if insulin pump therapy is not working well?

ThepumpremainsthepropertyofNHSLothian.Youwillbeaskedtosignanagreementtoreturnthepumpifitisnotbeingusedappropriately.

Somepeopleexperiencedifficultieswithinsulinpumptherapy.Thediabetesteamwillsupportyouwithanydifficulties,howeverifyou/yourchilddecidethatyouwouldprefernottobeoninsulinpumptherapy,youcanconvertbacktoinsulininjections.ThepumpwouldthenbetakenbackbyNHSLothian.

What do I do if I/my child would like to try insulin pump therapy?

Ifyouareinterestedininsulinpumptherapypleasediscusswiththediabetesteamatyournextclinicvisit.

INSULIN PUMPSINSULIN PUMPS

Pre Insulin Pump Process

Ifyouareinterestedininsulinpumptherapy,thisistheexpectedprocessfollowingyourinitialenquiry.

Family enquiry about insulin pump therapyDiscussionatclinic,andwritteninformationsenttofamily.

Cliniclettersent,includingdocumentationthatpumpinformationhasbeensent.

Family wish to proceedInitiationofpumpprocessatnextclinicvisit:

Familyneedtoanswerthreequestionsaboutinsulinpumptherapycorrectly.Pumpreferralsheetfilledinbydoctoratclinic.

Patients referred for pump therapy discussed at diabetes team meeting, last Monday of month

Patientaddedtopumpwaitinglist.Lettersenttofamilyconfirmingpatientonpumpwaitinglist.

Family invited to pump show

Referred for pre-pump psychology assessment

4 months before expected pump startPumpstartgroupsagreedbydiabetesteam.

Lettersenttofamilywithexpectedpumpstartdate.

4 months before expected pump startFamilymeetwithdietitian.

Dietitianassessmentandsignoff-acuratecarbohydratecounting.

3 months before expected pump start dateFamilymeetwithDNS.

DNSassessmentandsignoff-readinessforpumptherapyandexpectations.

2 months before expected pump start dateDatesandpaperworkforpumpstartsenttofamily

(seepumptrainingprogrammeprocess).

1 month before expected pump start datePumpdeliveredtofamilyhome.

Pumpagreementandpre-pumppreparationsheetsenttofamily.


Insulin Pump Start Process

Week 1

Childrenundersevenyearsofage

Groupsoftwofamilies

Visit1–ParentsattendRHSCforinsulinpumpeducation

Visit2–ParentsandchildrenattendRHSCforinsulinpump‘saline’start

Childrenoversevenyearsofage

Groupsofthreefamilies

Visit1–ParentsandchildrenattendRHSCforinsulinpumpeducationandinsulinpump‘saline’start

Week 2

Groupsoffamiliesattendforreviewofprogressfollowinginsulinpumpsalinestart,and‘golive’insulinpumpinsulinstart

Telephoneoncalladviceanddailyfollowupphonecallsfromdiabetesteam

Week 3

FamilyphoneDNSonWednesdaytoreviewBGreadingsandprogress

Week 4

Beginningofweek-Familysendininsulinpumpdownloadsforprevioustwoweeks

Downloadstosend: Devicesettings

Quickviewsummary

Logbookdiary

Modaldaybyhour

Endofweek–FamiliesattendRHSCforgroupreviewandeducationsessionwithdiabetesteam

Week 8-10

ReviewappointmentinWednesdayafternoondiabetesreviewclinic

PumpdownloadsforprevioustwoweekstobesenttodiabetesteamonMondaybeforeclinic


Top Tips When Starting on an Insulin Pump

Usethissectionasaguidefollowingyour/yourchild’spumpstartdate.Whenmoreexperiencedwithinsulinpumptherapy,youwillfindmoredetailedinformationinthe‘Day-to-DayInsulinPumpManagement’section.

1. When should BG readings be checked?

AimtocheckaBGreadingbeforeand2hoursaftercarbohydrateintake.Initially,alsocheckBGapproximately3hourlyovernighte.g.midnight,3amand6am.

RemembertorepeataBGreading1hourafteranysignificantpumpevente.g.setchange,treatingahypo,pencorrectionforhighbloodglucose/ketones.

BGreadingsshouldberecordedonthedailyrecordsheets,alongwithCHOintakeandinsulindosesforthefirstweekafterthepumpstart.Followingthis,youcanchangetotheMedtronicdailydiary,howeveryoumayprefertocontinueusingthedailyrecordsheetsforlonger.

2. What should I/my child eat and drink following the pump start?

Aimtoeatthreemealsperday.Asmallsnack,coveredwithabolus,betweenmealsisoptional.Ideallythereshouldbeatleast2hoursbetweenmealsandsnacksinitially,toassesstheinsulintocarbohydrateratios.

3. How does the pump calculate a bolus insulin dose?

Thepumpisprogrammedwithyourinsulintocarbohydrateratios,correctionfactor,andbloodglucosetargets.Thepumpcanthereforeworkouthowmuchbolusinsulinisrequired.Thereisalsoasafetyfeaturewhichpreventsanoverbolusofinsulin.Allthesefeaturesarecombinedinthepumpsoftware.Thebolusfunctioniscalledthe‘boluswizard’.

4. When should an insulin bolus be given?

Boluswizardshouldbeusedtocalculateanappropriateinsulinbolusforallcarbohydrateintake.Aimtogiveaninsulinbolus10minutesbeforemeals(upto20minutesbeforebreakfast),forthecarbohydratewhichyouknowyou/yourchildwilleat.IfmoreCHOthanexpectedisconsumed,bolusfortheadditionalCHOasitistaken.

Useboluswizardtoensurecorrectionbolusesaregivenwhenappropriate,everytimetheBGis>7mmol/L,throughoutthedayandnight.Ifthereisactiveinsulin,boluswizardwilltakethisintoaccount,andcalculatetheamountofcorrectionrequired.


5. How do I manage hypoglycaemia on a pump?

Giveshortactingglucoseasyouwouldhavedonepreviously.BGshouldbere-checkedafter10-15minutes.

IftherepeatBGis<4mmol/L,repeatthehypomanagement.

Thereisnoneedtogiveextra‘free’carbohydratewhentheBGhasrisento>4mmol/Lwhileusinganinsulinpump,asalltheinsulininthepumpisveryfastactinginsulin.

AnyadditionalCHOconsumedshouldbecoveredwithinsulinasindicatedbytheboluswizard.

Iftherearetwoseparateepisodesofhypoglycaemiawithinonehour,setatemporarybasalrateof50%(see‘Managementofhypoglycaemiaonaninsulinpump’flowchartonpage15).

RepeattheBGonehourafterthehypohasbeensuccessfullytreated,orsoonerifyouareconcerned.

IftheBGis>7mmol/Lwithintwohoursoftreatingahypo,youshouldnotgiveacorrectionbolus.IfeatingadditionalCHO,enteraBGof7mmol/Ltothepump,itwillthenonlybolusforthecarbohydrate.

IftheBGis>7mmol/Lmorethantwohoursaftertreatingahypo,useboluswizardtocalculateacorrectionbolus.

6. How do I manage high blood glucose readings >14mmol/L on a pump?

Theinsulingiventhroughtheinsulinpumpisveryfastactinginsulin,thereforeketonescandeveloprapidlyifthereisanyinterruptiontoinsulindelivery.

ImmediateactionisrequirediftheBGis>14mmol/L,initiallybycheckingforketones.Seethe‘ManagementofHyperglycaemia’and‘InsulinPumpTherapyDuringIntercurrentIllness’flowcharts.

Hyperglycaemiacanoccurformanyreasons.Itisimportanttocheck:

• Thereisnoleakagefromtheinfusionsetorcannula.

• Thecannulahasnotbecomedislodged.

• Thecannulaandinsertionsethasnotbeenwornformorethan72hours.

• Therearenolargeairbubblesintheinfusionset.

• Thecorrectbasalrateisset.

• Thecorrectbolusdosehasbeengiven(checkbolushistory).

• Thecannulaisnotinsertedintoalumpysite.

• Thepumpisworkingproperly(doa‘selftest’).

7. Can the insulin pump be disconnected?

Theinsulinpumpcanbedisconnectedforshortperiods,e.g.showering,dressing,datadownload.Aimtokeepthistimeasshortaspossible,notlongerthanonehour.

Smallchildrenareoftenonultralowbasalrates,whichwillbedeliveredatsettimes.

e.g. 0.025units/hour-thiswillbedeliveredasabolusoneachhour(00:00,01:00,02:00etc).

0.05units/hour-thiswillbedeliveredasabolusof0.025unitsoneachhalfhour(00:00,00:30,01:00,01:30etc).

Thereforedonotdisconnectthepumpatthesetimes.

8. What if I think there is a problem with the pump?

TreatahighBGfollowingthe‘Hyperglycaemia’flowchart(page16).

Doaselftest.Iftheproblempersists,contacttheMedtronichelpline.

Ifthepumphasfailed,youwillneedtoreverttoinsulininjections,usingyourprepumpstartinsulindoses.

9. How do I manage activity following the pump start?

Theexpectationisthatthepumpstartweekwillinitiallybea‘quiet’week.Wewillencourageagradualincreaseinactivitytonormallevelsafterthefirstfewdays.

Whenthereisplannedexercise,setatemporarybasalrate(70%oftheusualbasal)starting60minutesbeforeandcontinuinguntil60minutesaftertheplannedexercise.Atemporarybasalratecanbecancelledatanytime.

Ifthereisunplannedexercise,additionalcarbohydrateisrequired,justasyouhavedonepreviously,topreventahypo.Atemporarybasalratemaystillberequiredifexerciseismoderateandlastslongerthan30minutes.Theeffectofalowerbasalratetakesuptoanhourtohaveanybenefit,whichiswhytheextraCHOisneededatstartofexercise.


Day-to-Day Insulin Pump Management

1. What are the blood glucose (BG) targets while on pump therapy?

Thebloodglucosetargetshouldbesetat5-7mmol/Lonthepump,toallowboluswizardtocorrecttothistarget.

Generally,BGreadingsbeforemealsandbeforebedof4-8mmol/Lareacceptable,andwouldnotpromptachangeinbasalinsulinrates.

Twohoursafterameal,aBGof<9mmol/Lisacceptable.

IftheBG2hoursafteramealisabovetarget,increasetheinsulintocarbohydrateratio(ICR)byapproximately10-20%.Youwillthereforemakingminoradjustmentsregularly.

Forexample,ifyouwereusing1unit:13grams,changeto1unit:11grams.

2. When should insulin boluses to cover carbohydrate be given?

Givethebolustocovercarbohydrate10minutesbeforethemeal(orupto20minutesbeforebreakfast),forwhatyouknowwillbeeaten.Thiswillresultinoptimalbloodglucosecontrol.

BolusforanyadditionalCHOassoonasitiseaten(withoutenteringarepeatBG).

Rememberthatinsulinisabsorbedmorequicklybytheeffectsofexerciseandheat.Donotwait10-20minutesbeforeeatingifimmediatelyafterahypo.

3. How do I know if the basal rates need to be adjusted?

Wesuggestthatyouperformabasalratereviewevery4-6weeks.Reviewonlyonetimeintervalperday.

Ifbloodglucoseis4-8mmol/Lbeforeamealoratbedtime,omitthenextmealandsnack(orgiveaCHOfreemeal/snack)andcheckBGeverytwohours.Foranovernightbasalreview,havealightlowfatmealat5pm,thennothingafterwards.

TheBGshouldstaywithin2mmol/LoftheoriginalBGreading.

Carryoutthebasalratereviewprocessfrom:

a) Beforebreakfasttobeforelunch

b) Beforelunchtobeforetea

c) Beforeteatoafterbedtime

d) Overnight

Ifthebloodglucoselevelsriseorfallbymorethan2mmol/L,makeadjustmentstothebasalratestwohoursbeforetheriseorfall.

Whileperformingabasalratereview,donotgiveacorrectionbolusunlesstheBGis>14mmol/L,sothatyoucanseethebasalpatternclearly.

Once stable, checking BG before and 2 hours after meals as an 8 point profile is the ideal daily profile.



Wesuggestthefollowingchanges,basedontotaldailydoseofinsulin(TDD):

TDD Adjustment

TDDlessthan10units makeadjustmentsby0.025unitsperhour

TDD10-20unitsperday makeadjustmentsby0.05unitsperhour

TDD20-40unitsperday makeadjustmentsby0.1unitsperhour

TDDgreaterthan40unitsperday makeadjustmentsby0.2unitsperhour

Example

TDDofinsulinonpump:15.6unitsperday

Overnightbasalreview

1800–Lightmeal,30gCHOeaten,bolusgivenviaboluswizard.

Time Basal rate (units/hour) Blood glucose (mmol/L)

18:00 0.25 5.4

20:00 0.45 7.3

22:00 0.45 12.1

24:00 0.3 12.2

02:00 0.3 11.8

04:00 0.3 9.4

06:00 0.3 9.2

RiseinBG>2mmol/Lat22:00,soincreasethebasalrate2hoursbeforethisrise.

TDD15.6unitsperday,sochangebasalrateby0.05unitsperhour.

Newbasalrateat20:00=0.45+0.05=0.5unitsperhour.

4. Which insertion sites should be used, and how often do they need to be changed?

Cannulascanbesitedintheabdomen,thighs,hipsortopsofbuttocks.Thereisusuallytoolittlefatonayoungchild'sabdomentousethisasaninsertionsite.

Thecannulaneedstobere-sitedeverytwoorthreedays.

IfyouseetheBGtrendrisingcominguptothethirdday,thenyouwillneedtore-sitethecannulaeverysecondday.Thisismorecommoninyoungerchildren.

Aimtore-sitethecannulabeforeamealsothatyoucanbesurethesetisworking.

Avoidre-sitingthecannulabeforebed,asitwilltakesomehourstoseearisingBGifthereisaproblemwiththenewinsertionsiteandthebasalinsulinisnotinfusing.

Document the basal rate review readings, the date and any changes made in the diary.

Remember to rotate insertion sites – lumpy sites remain a common problem.


5. What is insulin sensitivity and what should it be set as?

Thisisthesameasa‘correctionfactor’.

Reviewthetotaldailydoseofinsulin(TDD)inutilities.Dividethisnumberinto100.Thisisyourinsulinsensitivity.

For example:

TDD=21units

Insulinsensitivity=100dividedby21=4.7

1unitofinsulinreducestheBGby4.7mmol/L

Thiscanbeadjustedfordifferenttimesoftheday,e.g.overnightmaybe1unitlowersby6mmol/L.

6. What is active insulin, and what should it be set as?

Activeinsulinisthebolusinsulinwhichhasbeendeliveredtoyourbody,buthasnotyetbeenused.Theactiveinsulinsettingmeansthedurationofinsulinaction,orhowlongabolusofinsulinwillremainactiveinthebodyforafteritisgiven.Thisisusuallysetas3hours.

Thiscanonlybecheckedifyouareconfidentthatthebasalratesarecorrect.

Youcanassesstheactiveinsulinprofilewithabolus:checkaBGbeforeameal,iftheBGisintarget,eatalowfatmealwithknownCHOcontent,usingboluswizardtogiveanormalbolus.

ChecktheBGhourlyforupto5hoursafterthemeal.Donoteatordrinkanysnacksorcarbohydratecontainingliquids,anddonotpartakeinanyexerciseoverthisperiod.

ReviewhowlongittakesfortheBGtocomebacktothepremeallevel(+/-2mmol/L).Ifitcomesbacktorangein3hours,activeinsulinshouldbesetas3hoursonthepump.Ifittakesalongerorshortertimetocomebacktorange,theactiveinsulincanbeadjustedaccordingly.

7. What are composite boluses?

Square wave: thebolusisgivenevenlyoveraperiodoftime(setfrom0.5–8hours).

Thisisusefulforhighfatmeals,lowglycaemicindex(GI)foods,orextendedmeals(e.g.buffets).AhighBGbeforethemealneedstobecorrectedwithaseparatenormalbolus.

Dual wave: thisisacombinationofanimmediatenormalbolus,followedbyasquarewavebolus.

ThisisusefulformealswithbothrapidlyandslowlyabsorbedCHO.Whensettingupadualwavebolus,yousetboththepercentageofinsulingivenbynormalandsquarewavebolus,andthetimethesquarewaveisgivenover.AhighpremealBGcanalsobecorrectedwithadualwavebolus.

e.g.50%normalbolus50%squarebolusover4hours.

Seetheexample:Medtronichandbook(page98/99)

Insulin sensitivity = 100 divided by TDD


Exercise and Activity on Insulin Pump Therapy

Keep a record of what you do, as you will learn what best suits you/your child with time and experience.

When should I check a BG?

Check a BG before exercise

AimforaBG6-8mmol/Lbeforeexercise.

IftheBGis4-6mmol/L,giveasmall‘free’carbohydratesnackbeforeexercise(i.e.donotcoverthiswithabolus).

IftheBGisabove8mmol/Ltherearetwooptions:

1. Giveacorrectionbolus,andthengiveextrafreeCHOfree(seebelow).ThisisthebestoptioniftheBGis>10mmol/L.

2. Donotgiveacorrectionbolus,anddon’tgiveadditionalfreeCHOforbrief/moderateexercise.ThisisthebestoptioniftheBGis8-10mmol/L.

IftheBGis>15mmol/Lwithketones-don’texercise.Followthe‘Hyperglycaemia’flowchart(seepage16).

IftheBGis>15mmol/Lwithoutketones–itisstilloktoexercise,e.g.justafteramealwhenreducedinsulinwasgiveninpreparationforexercise.

Check BG at least hourly during sport

Thismayneedtobemorefrequentsoonafterstartingpumptherapytolearnyour/yourchild’sownresponse.

Check BG after sport

ConsiderreplenishingenergystoreswithadditionalCHO(seeexercisemanagementsection).

How do I manage mild to moderate activity?

Mild or brief activity

Ifexerciseisbriefandmild,donotalterthebasalrates,anddonotremovethepump.SomepeoplefindtheyneedasmallamountofadditionalCHO,e.g.0.25gofCHOperkgofbodyweightperhourofactivity.

Planned moderate activity

Ifexerciseifplanned,youshouldsetatemporarybasalrate.Thereducedbasalrateshouldstart60minutesbeforetheexercise,andcontinueforatleast60minutesaftertheexercise.Thismayneedtobetailoredaccordingtotheresponseinbloodglucose.Weadvisestartingwitha30%reduction(i.e.setas70%temporarybasal),butthiscanvaryfrom10-50%reduction.

Example 1

Thesunhasjustcomeoutsoyouaregoingtotakeyourchildtotheplaypark,hopefullyforabout1hourifitstaysdry.Yourchildweighs20kg.TheirBGis6.3mmol/Lbeforeyouleavehome.

Whileattheparkyourchildwillbedoingmoderateexercise.

Moderateexercise,soneed0.5g/kg/hrofCHO,i.e.0.5x20x1=10gperhour(or5gfor30minutes)withoutabolus!

Thiscanbeadjustedwithexperienceanddependingonyourchild'sactivitylevelwhileatthepark.

Example 2

Yourchildhasfootballtrainingfrom3.30pmtill4.30pm.Yousetatemporarybasalratestartingat2.30pm(60minutesbeforefootballtrainingbegins),witha30%reduction(setas70%temporarybasal).Yousetthisfor3hours(i.e.60minutesbefore,60minutesduring,and60minutesafterfootball).

Youtestyourchild’sBGjustbeforeyouleaveanditis9.8mmol/L.Thisisabovetarget,butyoudonotgiveacorrectionbolus,asyouknowhehashadlessinsulinforthelast60minutes.YoucheckhisBGafter30minutesoffootballanditis6.8mmol/L,sohehasadrinkofwater.

Justattheendoffootballtraining,yourchild’sBGis4.6mmol/L.Youleavethetemporarybasalonforanother60minutes,andplantocheckaBGatthistime.

Unplanned moderate activity

Ifexerciseisunplanned,ortheduration/intensityisunknown,theonlyoptionistotakeadditionalCHOatthebeginningofandduringexercise.Youshouldalsoseta70%temporarybasalatthebeginningoftheactivity,fortheexpectedlengthofactivity,and60minutesafterwards.Thiscanbecancelledatanytime,forexampleiftheperiodofactivitydoesnotlastaslongasexpected.

Ifexerciseismoderate,consumeadditionalCHO.Approximately0.5gofCHOperkgofbodyweightisneededperhourformoderateactivity.DonotbolusforthisCHO,ifyouhavenotsetatemporarybasalrate60minutespriortoactivitystarting.

Altering bolus insulin with moderate exercise

Ifexerciseiswithin2hoursofameal,thebolusinsulincanbereduced.Thisishelpfulforplannedexerciseofknownintensityandduration.ItavoidstheneedforextraCHOonafullstomach.WorkouthowmuchCHOisneededfortheexercise.SubtractthisamountofCHOfromtheamountduetobeeatenatthemeal,thenbolusfortheremainingamountofCHO.

e.g. Youweigh30kg,andyouaregoingtoexercise(moderately)foronehour.

Moderateexercise,soyouneed0.5g/kg/hrofCHOi.e.0.5x30x1=15gofCHOperhour.

Youareabouttoeatamealcontaining75gofCHO.

Yousubtract15gofCHO(forexercise)from75gi.e.75g-15g=60g.

Youbolusfor60gofCHO.



How do I manage strenuous activity?

Check a BG before exercise

TheBGbeforestrenuousexercisemustbe5-15mmol/L,ideally5-10mmol/L.ThehigherlimitwouldonlybeacceptableifyouhaveeatenCHOwithoutabolus,orwithareducedbolus,orusedareducedtemporarybasalrateinpreparationforexercise.

Set a temporary basal rate

Consideratemporarybasale.g.30-70%reduction(setas70%to30%temporarybasalrate),beginning60–90minutesbefore,andcontinuing60-90minutesafterstrenuousexercise.

Aperiodof4-8hoursoftemporarybasalrate(50-70%ofusualbasalrate)mayberequiredfollowingexhausting/prolongedactivity,duetotheriskofdelayedhypoglycaemia.

Consume additional carbohydrate

Thismayberequiredinadditiontosettingatemporarybasalrate.Youneedabout1gofCHOperkgofbodyweightperhourofexercise,andthiswouldnotbecoveredwithabolus.ExperiencewillbegainedbyrecordingBG’sduringandafterexercise.IftakinganyadditionalCHO,useareducedboluse.g.50%lessthanwouldusuallybegiven.

Reduce the bolus insulin after exercise

Thebolusinsulinforamealafterstrenuousexercisecanalsobereducedby30-70%,dependingontheactivity–seethe‘ExerciseandSportsection’fordetails.

Can I remove the pump during exercise?

Youcandisconnecttheinsulinpumpduringsportifrequired,forexample,forcontactsports,orduringstrenuousactivitythatyouknowhaspreviouslyresultedinhypoglycaemiadespiteatemporarybasalandadditionalcarbohydrate.

Pumpscanbedisconnectedforuptoonehour.YoumustcheckaBGduringexerciseifthepumpisdisconnected.

Withexperience,longersessionsoffthepumpcanbemanaged.Pleasediscussthiswiththediabetesteam,asfurtherindividualisedinformationisavailable.

Check BG regularly during and after strenuous exercise. Recording BG’s, pump settings and CHO intake will help to guide management of future exercise sessions.


Notes (A)• Onaninsulinpump,onceBG>4mmol/Lasnackisnotessential.

• IfgivingfoodgiveaninsulinbolusforCHOusingcurrentinsulin:CHOratiousingboluswizard.

• Bolusmaybegivenafterfoodifpoortoleration/vomitinganticipated.

• DonotgiveacorrectionforBG>7mmol/Lfor2hoursafterhypotreatment.IfBG>7mmol/Ltheninput7mmol/Lintothepumptoensureacorrectionisnotgiven.

Notes (B)• Considerreasonbehindfrequenthypoglycaemia,i.e.intercurrentlyunwell,exercise-related,orthereisapatternofhyposdeveloping.

• Ifthereisapatternthenconsidertakingaction,i.e.seekmedicaladviceifunwell,considerlookingattheexercisemanagementroutineorconsidermakingalterationstobasalratesettings.

Give glucose as usual(10g of glucose, or see Hypoglycaemia section page 5)

Wait 10-15 minutes then recheck BG

BG now ≥4mmol/L(See Notes (A) below for further guidance)

Check BG 1-2 hourlyAim for BG target levels 5-7mmol/L

Hypoglycaemia twice in 1 hour OR 3 or more times in 2 hours

(See Notes (B))

Set a temporary basal rate at 50% for 2 hours

After 2 hours – Re-check BGAim for BG target levels 5-7mmol/L

BG remains <4mmol/L

Management of Hypoglycaemia BG <4mmol/L


<1.0mmol/L

Give correction bolus via pump and re-check blood glucose in 1 hour

BG

Carry on as normal and give further

corrections if required

yes

no

* Correctionbolusviapen:Giveasperthe‘SickDayManagement’flowchart.Youneedtoknowthetotaldailydose(TDD)ofinsulin(inutilitiesmenuonpump).Youwillrequirea10%or20%(ofTDD)correctiondependingonyourbloodglucoseandbloodketones.

**Onceyouhavegiventhepeninjection,disconnectthepumpandsetthepumptodeliverthesamebolusdosegivenbypeninjection.Allowthistorunthroughthetubinganddiscardit(e.g.intothesink/ontothefloor),beforereconnectingthepump.Thismeansthatthecorrectiondosewillbeshownonthepumpdownloads,andincludedinthepump’sactiveinsulincalculation.

no

yes

yes

no

≥1.0mmol/L

1. Give correction bolus via PEN device*

2. Remove pump and run bolus through set**

3. Change pump infusion set

4. Check insulin pump (self-test)

Re-check blood glucose in 1 hour

BG

Re-check blood glucose and blood ketones

in further 1 hour

BG blood ketones

Management of Hyperglycaemia BG ≥14mmol/L

Check ketones

Consider temporary basal rate

by further 25%


Continue to check BG 2 hourly until levels remain within target and blood ketones are <0.5mmol/L on normal basal rates

Levels reach targetyes

Insulin Pump Therapy During Intercurrent Illness

Blood glucose (BG) level ≥14mmol/L and ketones present Follow Hyperglycaemia Guidelines (page 20)

Blood glucose levels remaining above target Unwell and requiring additional background insulin

Check BG and ketones 1-2 hourly Aim for BG target levels 5-7mmol/L

Set a temporary basal rate at 125% for 2 hours

After 2 hours – Re-check BG and ketone levels

Notes

• Ensureplentyofsugar-freefluidsifthebloodglucoseishigh.

• Ensureadequatecarbohydrateintake.

• Aninsulinbolusmustbegiventocovercarbohydratecontentoffoodandfluids.

• Ifmanagingtoeat,thebolusinsulindosemayneedtobeincreasedtemporarilye.g.ifusuallyusinginsulintoCHOratio1unit:10g,changeto1unit:8g.

no

Consider or stop temporary basal rate

Levels Levels steady

Continue temporary basal

Levels


Troubleshooting – Pump Failure

What can cause a pump to stop delivering insulin?

• Thebatterycanrunout–thiswillnothappenwithoutwarningandyouhavebeensuppliedwithsparebatteries.

• Thepumpcanbedropped.

• Thepumpcanbedisconnectedbyaccident.

• Insulincanleakoutofagivingsetifitisnotconnectedproperly.

What do I do if I suspect a pump problem?

• Checkabloodglucosereading.

• IftheBGis>14mmol/L,checkforketonesandfollowthehyperglycaemia/intercurrentillnessflowchart.

• Changetheinfusionset.

• Ifatechnicalproblemwiththepumpissuspected,runa‘self-test’.(Dothisifthepumphasbeendropped).

• Ifthisdoesnotresolvetheproblem,removethepumpandswitchtosubcutaneousinsulininjectionsbybasalbolusregimen.

• Contactpumpcompanyfortechnicalhelp.

Telephone Advice

General advice

Itisexpectedthattheinformationgivenwhenyoucommencetheinsulinpumpwillallowyoutomanageproblemsthatariserelatingtodiabetes.

Telephoneadvicecanbeobtainedduringnormalofficehoursbycontactingthediabetesnursespecialists(0131 536 0375).

Pleasenotethatadviceregardingthemanagementofinsulinpumpsisnotavailableout-of-hours(i.e.evenings,weekendsandholidays).

Shouldyouencounterdifficultiesthatyouarenotabletosolveusingtheinformationthathasbeenprovided,youshoulddisconnectthepumpandrevertbacktosubcutaneousinsulininjections.

How do I switch from the insulin pump to insulin injections?

Theamountofinsulinrequiredbyinjectiondependsonthetotaldailydose(TDD)ofinsulinonthepump.Thisinformationcanbeobtainedfromthedailytotalsmenuonthepump(utilitiesmenu.

How do I calculate the dose of insulin required by injection?

Option 1Findthecurrenttotaldailybasalinsulindosein‘utilities-dailytotals’menu.Givethisaseitherlantusoncedaily,ordividebytwo,andgiveaslevemirtwiceaday.

Forbolusinsulindoses,usethecurrentinsulin:CHOratiosandinsulinsensitivity(correctionfactor)fromthepump(Novorapid/Humalog).

Option 2Usethelasttotaldailydoseofinsulin(TDD),eitherfromthe‘utilities-dailytotals’menu,thelastdiabetesclinicletter,orarecentpumpdownload.SplittheTDDinto50%basaland50%bolus.Basalinsulincaneitherbegivenaslantusoncedaily,ordividebytwoandgiveaslevemirtwiceaday.

Forbolusinsulindoses,usethecurrentinsulin:CHOratiosandinsulinsensitivity(correctionfactor)fromthepump(Novorapid/Humalog).

Option 3Ifthepumphasfailedandyoucannotaccessthesettings,andyoudonothavearecentdiabetesclinicletter,orarecentpumpdownload,estimatethetotaldailydoseofinsulin(TDD)by:

TDD=Weight(kg)x0.8

Dividethisinto50%basaland50%bolus.Givethebasalinsulinaslantusoncedaily,ordividebytwoandgiveaslevemirtwiceaday.

Ifyoudonotknowthecurrentinsulin:CHOratios,the50%bolusinsulincanbedividedbythreeandgivenateachmeal(Novorapid/Humalog).



Additional very fast acting insulin may be required outside of mealtimes as per the Sick Day Management section.

Example

TDDoninsulinpump 24units

50%basal 12unitsLevemir6unitsinthemorningand6unitsintheeveningORLantus12unitsoncedaily.

50%bolus Usetheinsulintocarbohydrateratioandcorrectionfactorfromthepumpsettingsatmealtimes.Alternatively12units(4unitsatbreakfast,4unitsatlunch,4unitsattea)

Admission to Hospital While on an Insulin Pump

Insomesituationsitispossibletocontinueonaninsulinpumpifyou/yourchildare/isadmittedtohospital,howevertheremaybereasonswhyitisdeemedsafertodiscontinuetheinsulinpumpandswitchtosubcutaneousinjectionsduringahospitaladmission.

When is it not possible to continue on an insulin pump in hospital?

Inthefollowingsituationsyou/yourchildmustremovetheinsulinpumpandswitchimmediatelytoinsulinbysubcutaneousinjectionorIVinsulininfusion.

• Diabeticketoacidosis–thepumpwillbedisconnectedandinsulinandfluidswillbestartedthroughaninfusionintothevein.

• Ifyou/yourchildare/isdrowsyorunconscious.

• Ifyou/yourchildare/isseriouslyillandrequireadmissiontotheintensivecareunit.

• Ifthereisnoonecontinuouslypresentontheward(parentorcarer)toperformallpumpcare.

• Ifyou/yourchildhaveamajorpsychiatricdisturbance.

• Ifyoudonothaveenoughconsumables(parentsshouldhaveallconsumablesrequiredforthedurationoftheadmission).

• Othersituationsasdeterminedbythemedicalstaff.


Guidance for In-patients Remaining on an Insulin Pump

Providingtherearenocontra-indications(aslistedabove)patientsmayremainontheirinsulinpump.Itisexpectedthattheparent/carerwillberesponsibleforthemanagementoftheinsulinpumpatalltimes duringtheadmission.

What documentation is needed for in-patients on insulin pumps?

• Wewillaskyoutosignaformindicatingthatyouwillberesponsibleformanagingyourchild’spumpanddocumentingpumpsettings.

• Wewillaskyoutodocumentthebasalrates,bloodglucose,bloodketones,carbohydrateintakeandbolusinsulingivenondailydiarysheets(thesameasthoseusedafterthepumpstart).

Who will operate the insulin pump on the ward?

• Aparentorguardianmustbeabletostaywiththechildatalltimesduringtheadmission.

• You/yourchildmustoperatethepumpduringtheadmission.

• You/yourchildmustmakeanyadjustmentsonthepump.

• Theflowchartsformanagementofhypoglycaemia/hyperglycaemiaandsickdayswillbeavailableontheward.

What happens if my child needs to have an operation?

Theinsulinpumpmayberemovedforshortprocedures(thetotaltimeoffthepumpshouldnotbemorethan60minutes)suchasforanMRIorCTscan.Iftheprocedurewilltakelongerthan60minutes,itmaybepossibletostayonthepumpwithguidancefromthediabetesteam,butitmaybenecessarytocomeoffthepumpandswitchtoinsulininjectionsoraninfusionofinsulinintoavein.

Radiology investigations

• TheinsulinpumpmustberemovedbeforeenteringtheMRI/CTsuite.ThisisbecausethemagnetintheMRIscannerwillcausethepumptofail.

Minor surgery

• Insulinpumpsmaybeused,continuingonabasalrateduringfastingperiodsandthesurgicalprocedure.

• Thediabetesteamwilldiscusswiththeanaesthetistpriortotheprocedure.Bloodglucosewillbemonitoredhalf-hourlyduringtheprocedure.

• Bolusescanbegiventhroughthepumpasusual,onceeatinganddrinkingaftertheprocedure.

Major surgery

• Thepumpneedstoberemovedandaninfusionofinsulinthroughadripintotheveinwillbecommenced.


Parent/Carer Consent Form

Continuation of insulin pump therapy during in-patient stay

Foryourchild’ssafetyduringthisadmission,werequestthatyouagreetothefollowingrecommendations.Ifyoufeelthatyoucannotagreetotheserecommendations,wewouldliketotreatyourchild’sdiabeteswithinsulininjectionsandrequestthatyoudiscontinuetheuseofyourchild’sinsulinpump.

As the parent/carer during my child’s admission to hospital:

• Iamtrainedtousetheinsulinpumpandwillremaininthehospitalforthedurationoftheadmission.

• Iwillmanagetheinsulinpumpduringtheadmission.

• Iwillprovidealltheequipment,consumablesandinsulinrequiredforthedurationoftheadmission.

• Iwillrecordthepumpsettings,basalrates,bloodglucose,ketones,carbohydrateintake,insulinbolusesonthe‘insulinpumpin-patientrecord’chartwhichwillbekeptintheyellowfolderbythebedside.

• Iwillallownursingandmedicalstafftohaveaccesstothe‘insulinpumpin-patientrecord’atalltimes.

• Iwillchangetheinfusionsetevery48–72hoursorasrequiredaccordingtothehyperglycaemiaorintercurrentillnessflowchart.

• IfIcannotmanagethepump,theinsulininfusionpumpwillbedisconnectedandinsulininjectionscommenced.

I also understand that the pump may be discontinued and a different insulin delivery given for any of the following:

• Contra-indications(aslistedabove).

• Therequestoftheconsultantresponsibleforthepatientduringtheadmission.

• Anx-rayprocedure(mayincludepumpremovalbytubingdisconnectand/orremovalofthepumpandtubing).

Parent/Carer

Signature............................................ Print................................................. Date...................

Witness

Signature............................................ Print................................................. Date...................


n.insulin-pumps.pdf - services.nhslothian.scot · INSULIN PUMPS PAGE 1 Introduction to Insulin Pump...

Documents

Transcript of n.insulin-pumps.pdf - services.nhslothian.scot · INSULIN PUMPS PAGE 1 Introduction to Insulin Pump...