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Advanced Pump Management. Gary Scheiner MS, CDE Integrated Diabetes Services 333 E. Lancaster Ave., Suite 204 Wynnewood, PA 19096 (877) 735-3648 (610) 642-6055 www.integrateddiabetes.com gary@integrateddiabetes.com. Advanced Pump Management. Basal Insulin Regulation Bolus Regulation

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advanced pump management
Advanced Pump Management

Gary Scheiner MS, CDE

Integrated Diabetes Services

333 E. Lancaster Ave., Suite 204

Wynnewood, PA 19096

(877) 735-3648

(610) 642-6055

www.integrateddiabetes.com

gary@integrateddiabetes.com

advanced pump management1
Advanced Pump Management
  • Basal Insulin Regulation
  • Bolus Regulation
  • Physical Activity Adjustment
  • DKA Prevention
  • Temporary Basal Rates
  • Prolonged Boluses
  • Alternate Basal Patterns
basal insulin regulation
Basal Insulin Regulation
  • Basal Insulin’s One And Only Job Is To Hold Blood Glucose Levels Steady In the Absence of Confounding Influences*

* Food, Exercise, Bolus Insulin, Unusual Hormonal Conditions (illness, rebounds, menstruation)

basal insulin regulation1
Basal Insulin Regulation

Conditions for Testing Basal Rates:

  • No food or bolus for at least 4 hrs prior
  • Last meal/snack low in fat
  • No food or bolus during test phase (water/diet drinks OK)
  • BG above 80 (4.4 mmol), below 250 (13.9) throughout
  • No lows for previous 12 hrs
  • Stay connected, no stopping/suspending
  • Exercise OK up until test phase (if usually performed)
  • No heavy activity during test phase
  • Do not run test if sick or just prior to/start of period
basal insulin regulation2
Basal Insulin Regulation

Sample Basal Testing Schedule

basal insulin regulation3
Basal Insulin Regulation

Average basal profiles*

* Diabetes Research & Clinical Practice (2005) 14-21.

basal insulin regulation4
Basal Insulin Regulation
  • Currently:

.30 3am-9am,

.25 9am-3am

  • Skipped Breakfast
  • BG results:

6am 109 (6.1)

8am 201 (11.2)

10am 230 (12.8)

12pm 224 (12.4)

Example 1: Sara Smiley

  • Interpretation:
    • Sharp rise 6am-8am
    • Modest Rise 8am-10am
    • Stable 10am-12 noon
  • Adjustments:
    • Basal by .1 5a-7a
    • Basal by .05 7a-9a
  • Repeat test from 6a-12p
bolus insulin regulation
Bolus Insulin Regulation

I:C Ratios:

  • The correct ratio should match pre-meal BG 3-4 hours (not 2!) after eating
  • I:C Ratio often varies from meal to meal

(bkfst dose > lunch & dinner)

bolus insulin regulation1
Bolus Insulin Regulation

Correction Boluses:

  • 1500*-Rule (aggressive) *83 if mmol

(Total Daily Ins.)/1500 (83)

  • 1800**-Rule (conservative) **100 if mmol

(Total Daily Ins.)/1800 (100)

  • May vary day vs. night

(nighttime often 50% more than day)

physical activity adjustments1
Physical Activity Adjustments

Meal Bolus

Adjustment*

  • Low Intensity Cardio  25%
  • Mod. Intensity Cardio  33%
  • High Intensity Cardio  50%
  • Competitive/Anaerobic ???

* If activity is after meal

  • Basal
  • Adjustment**
  •  Basal rate 50%
  • Start basal reduction 1 hr pre-activity

** For activities lasting > 90 Min.

physical activity adjustments2

Carbohydrate Replacement Per 60 Minutes of Activity

50 lbs

100 lbs

150 lbs

200 lbs

250 lbs

Skating

7-10g

14-20g

20-30g

28-40g

35-50g

Gymnastics

8-12g

17-23g

25-35g

34-46g

42-57g

Soccer

13-17g

27-33g

40-50g

54-66g

67-82g

Physical Activity Adjustments
  • Snacking to prevent low (examples)
physical activity adjustments3
Physical Activity Adjustments

Watch Out for D’OH!

(Delayed Onset Hypoglycemia)

  • Following high-intensity exercise
  • Following extended- duration activity
  • May occur up to 24 hours afterwards
  • Extra snacks or reduction in basal insulin may be necessary
physical activity adjustments4
Physical Activity Adjustments

OK To Disconnect Up To 1 Hour w/ Activity

physical activity adjustments5
Physical Activity Adjustments

Alternatives to Disconnection:

 Wear It! (Sport Pack, Fanny Pack, Backpack Harness)

  • Re-Connect hourly & bolus 50% of missed basal rate
dka prevention
DKA Prevention

Normal Cellular Metabolism

dka prevention1
DKA Prevention

Metabolism

With

Insulin

Deficiency

dka prevention2
DKA Prevention

Progression

to DKA

Higher B.G.

+ More Ketones

+ Dehydration

**KETOACIDOSIS**

dka prevention3
DKA Prevention

Causes of insulin deficiency in Pump Therapy

  • Malabsorption (site problems)
  • Insulin Spoilage
  • Tubing or infusion set clogs
  • Leaks where the cartridge connects to the tubing
  • “Tunneling”/Leakage at the infusion site
  • Air pockets in the tubing
  • Dislodgement of the canula from beneath the skin
  • Improper or insufficient priming
  • Extended pump suspension or disconnection
temporary basal rates
Temporary Basal Rates
  • Basal Insulin Should Hold BG Steady Under Normal Conditions.
  • How Often Is Life Under “Normal Conditions”?
temporary basal rates3
Temporary Basal Rates
  • Predictable Stress
temporary basal rates4
Temporary Basal Rates
  • Extended Inactivity
temporary basal rates5
Temporary Basal Rates
  • Menstrual Cycles
temporary basal rates6
Temporary Basal Rates
  • Prolonged Activity
temporary basal rates7
Temporary Basal Rates

Prevention of D’OH! (Delayed-Onset Hypoglycemia)

temporary basal rates9
Temporary Basal Rates

Offsetting

Bedtime

Insulin-On-Board

temporary basal rates10
Temporary Basal Rates
  • BG Dropping (w/nausea)
prolonged boluses
Prolonged Boluses
  • Description

Normal/Standard Boluses are delivered within a few minutes; peak is approx. 1 hr, duration approx. 4 hours

Prolonged boluses are delivered over a period of a couple of hours; peak is delayed/blunted and duration is extended.

prolonged boluses1
Prolonged Boluses
  • Purpose

To do a better job of matching the blood sugar rise caused by slow-digesting foods.

prolonged boluses2
Prolonged Boluses
  • Applications

Very Large Portions

Low-Glycemic-Index Foods

Meals/Snacks that take a long time to consume

Gastroparesis

prolonged boluses3
Prolonged Boluses

Options for slow-digesting food:

Normal Bolus

prolonged boluses4
Prolonged Boluses

Options for slow-digesting food:

Square/Extended Bolus

prolonged boluses5
Prolonged Boluses

Options for slow-digesting food:

Dual/Combination Bolus

alternate basal patterns
AlternateBasal Patterns
  • Called Pattern A/B (Medtronic), Prog 2-4 (Animas), Pattern 1-4 (Deltec), Basal 2,3 (OmniPod)
  • Useful when basal changes are needed for several days (or more) in succession
alternate basal patterns1
AlternateBasal Patterns

Menstrual cycle phases

Extended illness

Recovery from surgery

Periodic use of steroid medications

Seasonal sports

Off-day vs. work/school-day

Extended travel

Climate changes

Potential Uses:

only count the carbs you actually consume
Only count the carbs you actually consume!

Gary’s #1 Secret to Successful Pumping: