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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 Management. Basal Insulin Regulation Bolus Regulation

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Advanced Pump Management

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  1. 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

  2. Advanced Pump Management • Basal Insulin Regulation • Bolus Regulation • Physical Activity Adjustment • DKA Prevention • Temporary Basal Rates • Prolonged Boluses • Alternate Basal Patterns

  3. 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)

  4. 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

  5. Basal Insulin Regulation Sample Basal Testing Schedule

  6. Basal Insulin Regulation Average basal profiles* * Diabetes Research & Clinical Practice (2005) 14-21.

  7. 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

  8. 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)

  9. 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)

  10. Physical Activity Adjustments

  11. 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.

  12. 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)

  13. 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

  14. Physical Activity Adjustments OK To Disconnect Up To 1 Hour w/ Activity

  15. Physical Activity Adjustments Alternatives to Disconnection:  Wear It! (Sport Pack, Fanny Pack, Backpack Harness) • Re-Connect hourly & bolus 50% of missed basal rate

  16. DKA Prevention Normal Cellular Metabolism

  17. DKA Prevention Metabolism With Insulin Deficiency

  18. DKA Prevention Progression to DKA Higher B.G. + More Ketones + Dehydration **KETOACIDOSIS**

  19. 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

  20. DKA Prevention

  21. Temporary Basal Rates • Basal Insulin Should Hold BG Steady Under Normal Conditions. • How Often Is Life Under “Normal Conditions”?

  22. Temporary Basal Rates • High-Fat Food

  23. Temporary Basal Rates • Illness

  24. Temporary Basal Rates • Predictable Stress

  25. Temporary Basal Rates • Extended Inactivity

  26. Temporary Basal Rates • Menstrual Cycles

  27. Temporary Basal Rates • Prolonged Activity

  28. Temporary Basal Rates Prevention of D’OH! (Delayed-Onset Hypoglycemia)

  29. Temporary Basal Rates • Alcohol

  30. Temporary Basal Rates Offsetting Bedtime Insulin-On-Board

  31. Temporary Basal Rates • BG Dropping (w/nausea)

  32. 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.

  33. Prolonged Boluses • Purpose To do a better job of matching the blood sugar rise caused by slow-digesting foods.

  34. Prolonged Boluses • Applications Very Large Portions Low-Glycemic-Index Foods Meals/Snacks that take a long time to consume Gastroparesis

  35. Prolonged Boluses Options for slow-digesting food: Normal Bolus

  36. Prolonged Boluses Options for slow-digesting food: Square/Extended Bolus

  37. Prolonged Boluses Options for slow-digesting food: Dual/Combination Bolus

  38. 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

  39. 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:

  40. Only count the carbs you actually consume! Gary’s #1 Secret to Successful Pumping:

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