Pumping How Do I Start? John Walsh, P.A. Author: Pumping Insulin, Using Insulin (619) 497-0900

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Pumping How Do I Start? John Walsh, P.A. Author: Pumping Insulin, Using Insulin (619) 497-0900 www.diabetesnet.com www.diabetesnet.com Slide 2 What Well Cover Introduction to pumps Introduction to pumps Advantages of pumping Advantages of pumping Am I a candidate? Am I a candidate? How to choose a pump and infusion set How to choose a pump and infusion set What is needed to start What is needed to start Importance of data Importance of data Site preparation Site preparation Troubleshooting Troubleshooting Formulas that help Formulas that help Smart features Smart features Slide 3 Where Pumps Began Started ~1978 with conversion of portable chemotherapy pumps to delivery of insulin Started ~1978 with conversion of portable chemotherapy pumps to delivery of insulin The Autosyringe AS2C and Harvard Apparatus Mill Hill Infuser were first The Autosyringe AS2C and Harvard Apparatus Mill Hill Infuser were first Single basal, no memory Single basal, no memory 50 ml syringe on pump exterior 50 ml syringe on pump exterior Required dilution of insulin to U-36 or U-18 Required dilution of insulin to U-36 or U-18 1976 Biostator (top) and 1978 Autosyringe AS2C > Slide 4 The Basal-Bolus Concept Slide 5 Advantages Flexibility in meal timing & size Flexibility in meal timing & size Eat when you want to Eat when you want to Faster adjustment of insulin for exercise Faster adjustment of insulin for exercise Family activities are no longer tied to one persons needs Family activities are no longer tied to one persons needs Easier handling of illness, travel, or camping Easier handling of illness, travel, or camping Slide 6 Advantages More Consistent Insulin Action The same dose of NPH insulin given to the same individual varies by 25% from day to day The same dose of NPH insulin given to the same individual varies by 25% from day to day Order of variablility: NPH > Lente > Lantus > Detemir Order of variablility: NPH > Lente > Lantus > Detemir A pump has less variable insulin delivery at 3% A pump has less variable insulin delivery at 3% Slide 7 Advantages Precise doses, as small as 0.025 u, can be given Precise doses, as small as 0.025 u, can be given Manages the Dawn Phenomenon Manages the Dawn Phenomenon Improves control during growth spurts and adolescence Improves control during growth spurts and adolescence Reminders Reminders Slide 8 Who Is A Good Pump Candidate? Slide 9 Why Choose A Pump? A freer lifestyle A freer lifestyle Easier dose determinations Easier dose determinations Improved blood sugars Improved blood sugars Flexibility in meal timing and size Flexibility in meal timing and size Ability to exercise without losing control Ability to exercise without losing control Peace of mind Peace of mind Slide 10 When To Consider A Pump More than 3 injections per day More than 3 injections per day Tired of multiple injections Tired of multiple injections Frequent or severe hypoglycemia Frequent or severe hypoglycemia Hypoglycemia unawareness Hypoglycemia unawareness Elevated A1c Elevated A1c DKA or ER/hospital admission DKA or ER/hospital admission Strong Dawn Phenomenon Strong Dawn Phenomenon Require small, precise doses Require small, precise doses Less risk of complications Less risk of complications Slide 11 Insulin Pump Pro Less work Less work Simplified insulin dosing Simplified insulin dosing Precise delivery Precise delivery Greater impact in those with highest starting A1c Greater impact in those with highest starting A1c Slightly less insulin use per day Slightly less insulin use per dayCon More DKA More DKA More severe hypoglycemia More severe hypoglycemia A1c levels and frequency of DKA & hypoglycemia are similar to ICT A1c levels and frequency of DKA & hypoglycemia are similar to ICT Slide 12 What It Takes To Succeed A personal desire for better control A personal desire for better control Willing to adjust insulin doses to carb count, test results, and activity Willing to adjust insulin doses to carb count, test results, and activity Willing to monitor at least 4 times a day Willing to monitor at least 4 times a day Willing to keep an accurate record of BGs, boluses, and carb counts Willing to keep an accurate record of BGs, boluses, and carb counts Committed to solve problems and adapt lifestyle as needed Committed to solve problems and adapt lifestyle as needed Slide 13 Success For Kids On Pumps Supervision is required: kids BEGIN to develop self care skills at about age 10 Supervision is required: kids BEGIN to develop self care skills at about age 10 Family support is essential: an adult who can go to school, etc. Family support is essential: an adult who can go to school, etc. Communication with a health care team that is committed to pumps Communication with a health care team that is committed to pumps Adequate insurance and financial resources Adequate insurance and financial resources Assistance and support from teachers, friends, babysitters, grandparents, siblings Assistance and support from teachers, friends, babysitters, grandparents, siblings Slide 14 Features For Infants & Toddlers Little ones are ideal pump candidates if the parents are Little ones are ideal pump candidates if the parents are Delay or split boluses for fussy eaters Delay or split boluses for fussy eaters Small, user-friendly pumps offer precise dosing (0.05, 0.025, or 0.01 unit increments) Small, user-friendly pumps offer precise dosing (0.05, 0.025, or 0.01 unit increments) Lock out Lock out Worn between shoulder blades Worn between shoulder blades If a toddler likes to remove the infusion set, let them know what comes out must go right back in If a toddler likes to remove the infusion set, let them know what comes out must go right back in Slide 15 Help For Kids & Teens Growth spurts Growth spurts Dawn Phenomenon Dawn Phenomenon Easy coverage of snacks Easy coverage of snacks TDD and bolus history can be checked to ensure consistent dosing TDD and bolus history can be checked to ensure consistent dosing Faster adjustment of basals and boluses for changes in activity, etc Faster adjustment of basals and boluses for changes in activity, etc Slide 16 Special Teen Concerns Dating Dating Wearing, sharing Wearing, sharing Alcohol Alcohol Eating disorders Eating disorders Fast foods Fast foods Fabrication Fabrication Sleeping-in Sleeping-in Slide 17 Personal Effort Those who expect a pump to manage their diabetes for them will fail to optimize their own therapy. Learn how to adjust your basals and boluses for an excellent A1c! Slide 18 First Steps Toward A Pump Keep detailed records Keep detailed records Consider your (and your childs) motivation Consider your (and your childs) motivation Peer group, acceptance issues, family support Peer group, acceptance issues, family support Look at available pumps Look at available pumps Which pump(s) does your insurance cover? Which pump(s) does your insurance cover? Talk with your doctor about a prescription Talk with your doctor about a prescription Visit a dietician to learn carb counting Visit a dietician to learn carb counting Slide 19 What To Learn How your pump works How your pump works How to count carbs How to count carbs How to interpret BG results and see BG patterns How to interpret BG results and see BG patterns When to increase and decrease basals and boluses When to increase and decrease basals and boluses How to adjust for high GI foods, extra activity How to adjust for high GI foods, extra activity Slide 20 How To Choose A Pump Slide 21 Pump Companies Who sell or plan to sell pumps in the US: Animas R1200 Animas R1200 Dana Diabecare III Dana Diabecare III Deltec Cozmo Deltec Cozmo Medtronic Paradigm Medtronic Paradigm Nipro Amigo Nipro Amigo Roche/Disetronic Roche/Disetronic Visit www.diabetesnet.com/diabetes_technology/ Slide 22 Things To Consider Look, feel, color Look, feel, color Features: reminders, child block, waterproofing Features: reminders, child block, waterproofing Size of basal and bolus increments Size of basal and bolus increments Infusion set choices Infusion set choices Safety and reliability Safety and reliability Customer support Customer support History History Ease of data analysis Ease of data analysis Add-ons: meters, covers, cases Add-ons: meters, covers, cases Slide 23 Todays Smart Pumps Easy dose calculations with Carb Factor and Correction Factor Easy dose calculations with Carb Factor and Correction Factor Precise insulin dosing (0.05 units or better) to allow basal rates to be set up for Dawn Phenomenon, etc. Precise insulin dosing (0.05 units or better) to allow basal rates to be set up for Dawn Phenomenon, etc. Tracks BOB to avoid insulin stacking Tracks BOB to avoid insulin stacking Reminders Reminders Slide 24 Todays Pumps When control is poor or varies greatly on one of todays pumps, the pump settings are incorrect. When control is poor or varies greatly on one of todays pumps, the pump settings are incorrect. Test and reset basal rates, carb and correction factors until you have good control. Test and reset basal rates, carb and correction factors until you have good control. Garbage in.. Garbage in.. Slide 25 How To Choose An Infusion Set Slide 26 Infusion Sets Straight-In Teflon: Cleo, Inset, Ultraflex, Quik-Set Straight-In Teflon: Cleo, Inset, Ultraflex, Quik-Set Easier to insert, variety of depths (6, 8, 9 mm) Easier to insert, variety of depths (6, 8, 9 mm) Angled Teflon (Comfort, Tender, Easy, Silhouette): Angled Teflon (Comfort, Tender, Easy, Silhouette): Fewer failures Fewer failures Insertion site is visible Insertion site is visible Longer is more secure Longer is more secure Adjust angle to reach fat Adjust angle to reach fat Metal needles (Rapid-D or bent needle) Metal needles (Rapid-D or bent needle) As comfortable and often more reliable As comfortable and often more reliable Very short, multi-needle infusion sets expected soon Ver