Introduction To Pumping Starting And Success
tarix 25.01.2017 ölçüsü 4,52 Mb. #6351
John Walsh, P.A., C.D.E. North County Endocrine 700 West El Norte Pkwy Escondido, CA 92126 (760) 743-1431 or The Diabetes Mall (619) 497-0900 jwalsh@diabetesnet.com Highlights Why Pump? Who’s A Candidate? Pump Basics Brands And Features Smart Pump Advantages Infusion Sets How To Start Settings That Affect Control Wrap Up Origins The first insulin pumps appeared in 1978 when large portable chemotherapy pumps were converted to deliver insulin Autosyringe AS2C and Harvard Apparatus Mill Hill Infuser were early models Used large 50 ml syringe that required users to dilute insulin to U-36 or U-18 Had only one basal rate and no memory Reasons To Use A Pump Better Control –> Fewer Complications Poor Control Remains A Problem Exposure Versus Variability The Challenge Of Diabetes Bringing the A1c down smoothly takes effort Advantages Of Pumps Over MDI More reliable insulin action Fewer missed/skipped doses Precision – 0.05 u versus 0.5 u Automatic dose calculations Less insulin stacking A More Normal Lifestyle Flexible mealtimes Less hypoglycemia Flexible insulin delivery for exercise, skipping meals, erratic schedules, shiftwork Less hassle with travel and time zones Increased sense of well being Less anxiety while staying on schedule Plus reminders, history, accurate dose calculations, etc. Poor control, high A1c, wide BG excursions Nocturnal or frequent lows, hypo unawareness Frequent hospitalization/DKA Insulin sensitivity Varied or intense exercise/activity Dawn phenomenon, gastroparesis, pregnancy Varied work or school schedule, travel Insulin resistance, Type 2 diabetes Who Is A Pump Candidate? Candidate Requirements Realistic expectations Willing to monitor at least 4 times a day and keep records Counts carbs or otherwise able to quantify food intake for meals Willing to solve problems using diabetes management skills Comes to clinic for follow up Expectations Benefits For Infants & Toddlers Little ones are ideal pump candidates if parents are Delay or split boluses for fussy eaters Faster insulin adjustment for erratic activity Precise dosing – 0.025 basal and 0.05 bolus – assists infants who cannot convey hypoglycemia Sxs and have frequent illnesses Secure between shoulder blades and use lock out to avoid self dosing Benefits For Kids & Teens Better for growth spurts, hormone changes in puberty, Dawn Phenomenon Easy to cover snacks TDD and bolus history available to ensure consistent dosing Fast adjustments of basals and boluses for changes in activity/exercise Lessens impact of BG swings on top of peer pressure, struggle for independence, mood swings, college, and issues with alcohol, sex, drugs Pump Basics Terms Bolus – a quick release of insulin Carb bolus – covers carbs Correction bolus – lowers high readings Bolus On Board (BOB) – bolus insulin still active from recent boluses TDD – total daily dose of insulin (all basals and boluses) Basals And Boluses A pump more easily matches the realities of daily life. Basal: MDI versus Pump Brands And Features Insulin Pumps – 2007 Accu-Chek Spirit Animas 2020 Deltec CozMore 1800 Insulet Omnipod Medtronic Paradigm x22 Sooil Dana Diabecare IISG Things To Consider In Choosing A Pump Look, feel, color Features: reminders, child block, waterproofing Basal and bolus increments Infusion set choices Customer support Access to history and ease of data downloads and analyses Accessories: meter, covers, cases, PDA, smart phone Accu-Chek Spirit Boluses based on BG not on BOB 300 units 0.1 u basal & bolus increments Reversible display Side-mounted tactile buttons Accu-Chek Pump Configuration Software IR (direct line) control from optional Palm PDA or smartphone Database of 1,000 Calorie King foods in PDA Animas 2020 High contrast color screen for easy viewing Smallest mainstream pump Smallest basal rate increment – 0.025 u Waterproof – 12 ft for 24 hrs ezCarb meal bolus calculator ezBG correction bolus calculator ezBolus shortcut to give bolus Deltec Cozmo Most features: HypoManager, Weekly Schedule, Missed Meal Bolus , Disconnect Bolus, Basal Test, Meal Maker with CozFoods, Therapy Effectiveness Most flexible setup Direct BG entry from attachable Freestyle meter 300 units 0.05 unit basal and bolus increments Accurate bolus calculations IR download Best for blind or visually impaired Insulet Omnipod No tubing for easy wear Automatic cannula insertion and priming 200 units Limited to 72-80 hrs use Watertight Controlled by PDM or smartphone Medtronic Paradigm CGM displays BG, 3 hr trend, trend arrow, and advance warning of lows and highs Considered least accurate CGM for detection of lows Simple interface, less scrolling BD meter transmits BG directly Proprietary infusion sets History of carbs, TDD, %basal, %carb, %correction CareLink online software Pump + Meter Or Continuous Monitor With direct BG entry Deltec Cozmo + Freestyle CoZmonitor Omnipod + Freestyle Paradigm + BD Logic Dana Diabecare IISG With continuous monitor display Medtronic 5/722 + Paradigm RT Planned continuous monitor displays Abbott Navigator with Deltec Cozmo and Insulet Omnipod Animas and Lifescan AccuChek pump and monitor CGM Benefits Increased sense of security Immediate feedback – look and learn Improves control when used Worth out of pocket cost for many One unit available for about “a Starbucks a day” Reimbursement gradually catching on Look And Learn Excess night basal or bedtime bolus Breakfast bolus too small or too late Lunch bolus too small or afternoon basal too low Pump Advantages Advantages Of A Smart Pump Automatic carb and correction calculations based on: Easy to check history, basal/bolus balance, and correction bolus % Direct glucose entry from meter or continuous monitor Helpful reminders and alerts, weekly schedule, alternate basal profiles Helps Prevent Lows Better bolus accuracy with carb and correction factors Less insulin stacking due to tracking BOB after boluses are given A glucose test can reveal the current deficit – carb or insulin Faster reduction in insulin level for exercise Smaller pool of insulin under skin lessens risk of a large release in hot tub or weather More predictable insulin action Proper dosing is required! Helpful Reminders Reminders (alarms) to test BG after a bolus test BG after a low reading test BG after a high reading give a bolus at certain time or certain period of the day warn when bolus delivery was not completed, etc. change infusion site warn of low reservoir (20, 10, 5 and 0 units with an extra 10 “hidden” units for use in basal delivery) Infusion Sets Infusion Sets Five varieties: Self-contained (Omnipod) Slanted Teflon Straight-in Teflon Slanted metal Straight-in metal Three connections: Luer lock pumps: ~ 25 varieties Paradigm: ~ 4 varieties Omnipod: 1, auto-inserted Infusion Sets And Inserters Infusion set/site problems are a common cause for unexplained highs Use Sterile Technique For Site Prep 30% of people are constant staph carriers and 25% are intermittent. MRSA is now common. Prevent Wash hands Sterilize skin with IV Prep Place bio-occlusive IV3000 over site Insert infusion set through IV 3000 Steps for staph carriers: Use antiseptic soap all over body once every 1-2 weeks Occasionally, apply bacitracin ointment to inside of nose Tape The Tubing!!! One inch tape over the infusion line stops tugging Tape stops tunnelling – movement of teflon nder skin allows insulin to tunnel to the surface, causing unexplained highs Less skin irritation from movement Prevents pull outs At tug time, lose tape not insulin! Pump Start Prepare For Pump Start Use basal/bolus approach first with injections Use accurate carb counts Read Pumping Insulin and pump manual Practice with your pump as soon as it arrives View CD/DVD as you practice with your pump Preparation Ask how to discontinue your long-acting insulin Determine start-up settings for TDD, basal/bolus balance, carb and correction factors, and DIA Get prescriptions for insulin, test strips, IV Prep, IV 3000 dressings, etc. Have contacts for MD, CDE, pump company, pump rep, other pumpers Steps To Success Test often Keep great records (Smart Charts, download, etc) Take a bolus for every bite except when carbs are used to raise a low BG or when eating to compensate for exercise Take boluses early Write down a reason for every high and low Change infusion site on schedule and whenever unexpected highs occur Steps To Control Stop lows first Set a realistic DIA Determine an optimum TDD Set and test basals Determine starting carb factor with 450 Rule (450/TDD) and correction factor with 2000 Rule (2000/TDD) Periodically check basal/bolus balance Look for and correct unwanted patterns Stop Lows First Better 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 Find Your Optimum Doses! Start with an accurate TDD – 1. How much total insulin do you average a day? 2. Adjust the TDD – are highs or lows primary problem? Stay in basal/bolus balance – 50/50 or 45-65% as basal Use the 500 and 2000 Rules to estimate starting carb and correction factors Then adjust your basal and bolus doses TEST your blood glucose LOOK for blood sugar patterns ADJUST basals and boluses from your patterns Find Basals And Boluses From Starting TDD Duration Of Insulin Action (DIA) Time An accurate DIA time is critical to success on a smart pump Current research suggests that DIA times are NOT different between children and adults Shorter for those more sensitive to insulin, but NOT children in general But immediate factors can affect insulin action time: Shorter with activity and exercise Shorter in hot weather Longer with fat in diet DIA Tips If your pump often suggests boluses that you know are not enough, do not shorten your DIA– it is usually NOT the problem Instead, ask what is causing the highs and where more insulin is needed – in basal rates, in carb boluses, or both Exercise or activity can mobilize insulin faster but DO NOT shorten the DIA for occasional activity. Instead: lower boluses or basals ahead of time for planned activities or eat more carbs or lower basals for unplanned activities A low basal rate makes the DIA appear SHORT! Bolus Size (Relative To Wt) Affects The DIA Measured as units per kg(2.2 lb) Larger boluses have a longer duration of action. For 50 kg (110 lb) person: 0.3 u/kg = 15 u 15 u/kg = 7.5 u 0.075 u/kg = 3.75 u Recommendations For DIA Times DIAs on current pumps can be set from 2 to 8 hours. An inaccurate DIA can significantly impact control. When Major Control Problems Occur Adjust your TDD Determine the current TDD Lower it: For frequent lows If both highs AND lows occur – which comes first? Raise it: For a high A1c or a high average BG on your meter While keeping basal rates and the daily carb bolus total balanced Adjust The TDD For A High Avg. BG or A1c Example: someone with a TDD of 35 units and few lows. A1c = 9%, so more insulin is needed: about 3.2 units. Change Your TDD For A change in diet A loss or gain in weight Seasonal changes An overall change in activity Starting/stopping a sport Vacation Growth or start of puberty Menses Frequent highs Frequent lows High at B/L/D/Bed Low at B/L/D/Bed Low to high High to low Basal/Bolus Balance Basal Rates Should keep the blood sugar flat overnight or when a meal is skipped Relatively easy to test Set & Test Basals First How Many Basal Rates? Percentage of pumpers who use 1 to 10 basals per day from self reports of several hundred pumpers at insulin-pumpers.org Test Carb And Correction Factors After Basals Glycemic Index: Different Carbs Have Different Speeds Duration Of Carb Action Most carbs have most of their affect within 1 to 2.5 hours But delay can occur with complex carbs, more fat content, etc Carb Counting Accounts for half the day’s control Accuracy allows boluses to match carbs for post-meal control and a significantly lower A1c Made easier with automatic carb bolus calculations by pump Pump As Carb Counter Pump or external controller contains user-selected food list for accurate carb counting Easy carb calculation More accurate boluses Available in Animas 2020, Deltec Cozmo, PDM for Omnipod, and PDA for Spirit Carb Factor Carb factor – how many grams of carb are covered by 1 unit Carb bolus is based on: Your carb factor How many grams of carbs you plan to eat Your BG allows a correction bolus determination Amount of BOB still active (ALSO determined from BG!) A pump can determine the bolus needed for a meal when the carb count and the carb factor are accurate Visit your dietician to learn! Check Your Carb Boluses Does your carb factor work for LARGE meals? – half your weight (lbs) as grams of carb Are carb counts accurate? Are boluses given 20 min before meals when the glucose is normal? An Accurate Carb Factor Returns the blood sugar: to within 30 mg/dl (1.7 mmol) of where it started by the time selected for your duration of insulion action (DIA) with no lows within 5 hours after carb bolus given Carb Bolus Varieties Normal carb bolus Bolus taken immediately – most meals Extended or square wave bolus Bolus extended over time – gastroparesis Some now, some later – bean burrito, some pastas and pizzas, Symlin Most Carbs Much Faster Than “Rapid” Insulin Importance Of Bolus Timing Figure shows rapid insulin injected 0 min, 30 min, and 60 minutes before a meal Normal glucose and insulin profiles are shown in the shaded areas Bolus Timing Depends On Glucose Missed Boluses Cause High A1cs Start well– give a bolus for every bite! Use pump reminders or other reminder Review pump history once a week and work toward increasing the number of boluses Work toward solutions without blame Correction Factor Correction Factor – how many mg/dl (or mmol) the BG falls per unit of insulin Lets a smart pump determine the bolus needed to bring a high blood sugar to target Test to ensure accuracy – Does a correction bolus lower a high glucose safely to your target in 4-5 hrs? When BG Goes High, Keep All Culprits In Mind Bad infusion set or site Bad insulin Inaccurate carb counts Rebound from stress hormones Empty refrigerator syndrome Hypobolusemia Stress Pain Bottom Line If you don’t have great control on a smart pump, your pump settings are likely off. Where Next? Faster insulins – Biodel Viaject Can the loop be totally closed? Dual delivery pumps Wrap Up Pumps offer the latest technology for precise insulin delivery Benefits include more flexibility, less hypoglycemia, less glucose exposure and variability, and a healthier life Requires commitment & responsibility Training and follow-up is required to ensure safe and effective treatment Make the commitment to health. Start pumping! Questions And Discussion Dostları ilə paylaş:
