Pumping Pumping How Do I Start?How Do I Start?

John Walsh, P.A.John Walsh, P.A.Author: Author: Pumping Insulin, Using InsulinPumping Insulin, Using Insulin

(619) 497-0900 (619) 497-0900 www.diabetesnet.comwww.diabetesnet.com

What We’ll CoverWhat We’ll Cover

Introduction to pumpsIntroduction to pumps Advantages of pumpingAdvantages of pumping Am I a candidate?Am I a candidate? How to choose a pump and infusion setHow to choose a pump and infusion set What is needed to startWhat is needed to start Importance of dataImportance of data Site preparationSite preparation TroubleshootingTroubleshooting Formulas that helpFormulas that help Smart featuresSmart features

Where Pumps BeganWhere Pumps Began

Started ~1978 with conversion of Started ~1978 with conversion of portable chemotherapy pumps to portable chemotherapy pumps to delivery of insulindelivery of insulin

The Autosyringe AS2C and Harvard The Autosyringe AS2C and Harvard Apparatus Mill Hill Infuser were Apparatus Mill Hill Infuser were firstfirst

Single basal, no memorySingle basal, no memory 50 ml syringe on pump exterior50 ml syringe on pump exterior Required dilution of insulin Required dilution of insulin

to U-36 or U-18 to U-36 or U-181976 Biostator (top) and 1978 Autosyringe AS2C –>

The Basal-Bolus Concept The Basal-Bolus Concept

AdvantagesAdvantages

Flexibility in meal timing & sizeFlexibility in meal timing & size Eat when you want toEat when you want to Faster adjustment of Faster adjustment of

insulin for exerciseinsulin for exercise Family activities are no longer tied to Family activities are no longer tied to

one person’s needsone person’s needs Easier handling of illness, travel, or Easier handling of illness, travel, or

campingcamping

AdvantagesAdvantagesMore Consistent Insulin ActionMore Consistent Insulin Action

The same dose of NPH The same dose of NPH insulin given to the same insulin given to the same individual varies by individual varies by 25% from day to day25% from day to day

Order of variablility: Order of variablility: NPH > Lente > Lantus > NPH > Lente > Lantus > DetemirDetemir

A pump has less variable A pump has less variable insulin delivery at 3%insulin delivery at 3%

AdvantagesAdvantages

Precise doses, as small Precise doses, as small as 0.025 u, can be givenas 0.025 u, can be given

Manages the Dawn Manages the Dawn PhenomenonPhenomenon

Improves control during Improves control during growth spurts and growth spurts and adolescenceadolescence

RemindersReminders

Who Is A Who Is A Good Pump Candidate?Good Pump Candidate?

Why Choose A Pump?Why Choose A Pump?

A freer lifestyleA freer lifestyle Easier dose determinationsEasier dose determinations Improved blood sugarsImproved blood sugars Flexibility in meal timing and sizeFlexibility in meal timing and size Ability to exercise without losing controlAbility to exercise without losing control Peace of mindPeace of mind

When To Consider A PumpWhen To Consider A Pump More than 3 injections per dayMore than 3 injections per day Tired of multiple injectionsTired of multiple injections Frequent or severe hypoglycemiaFrequent or severe hypoglycemia Hypoglycemia unawarenessHypoglycemia unawareness Elevated A1cElevated A1c DKA or ER/hospital admissionDKA or ER/hospital admission Strong Dawn PhenomenonStrong Dawn Phenomenon Require small, precise dosesRequire small, precise doses Less risk of complicationsLess risk of complications

Insulin PumpInsulin Pump

ProPro Less workLess work Simplified insulin dosingSimplified insulin dosing Precise deliveryPrecise delivery Greater impact in those Greater impact in those

with highest starting A1cwith highest starting A1c Slightly less insulin use Slightly less insulin use

per dayper day

ConCon More DKAMore DKA More severe More severe

hypoglycemiahypoglycemia A1c levels and A1c levels and

frequency of DKA & frequency of DKA & hypoglycemia are hypoglycemia are similar to ICTsimilar to ICT

What It Takes To SucceedWhat It Takes To Succeed

A personal desire for better control A personal desire for better control Willing to adjust insulin doses to carb Willing to adjust insulin doses to carb

count, test results, and activitycount, test results, and activity Willing to monitor at least 4 times a dayWilling to monitor at least 4 times a day Willing to keep an accurate record of Willing to keep an accurate record of

BGs, boluses, and carb countsBGs, boluses, and carb counts Committed to solve problems and adapt Committed to solve problems and adapt

lifestyle as neededlifestyle as needed

Success For Kids On PumpsSuccess For Kids On Pumps

Supervision is required: kids BEGIN to Supervision is required: kids BEGIN to develop self care skills at about age 10develop self care skills at about age 10

Family support is essential: an adult who can Family support is essential: an adult who can go to school, etc.go to school, etc.

Communication with a health care team that is Communication with a health care team that is committed to pumpscommitted to pumps

Adequate insurance and financial resourcesAdequate insurance and financial resources Assistance and support from teachers, Assistance and support from teachers,

friends, babysitters, grandparents, siblingsfriends, babysitters, grandparents, siblings

Features For Infants & ToddlersFeatures For Infants & Toddlers

Little ones are ideal pump candidates if the Little ones are ideal pump candidates if the parents areparents are

Delay or split boluses for fussy eaters Delay or split boluses for fussy eaters Small, user-friendly pumps offer precise Small, user-friendly pumps offer precise

dosing (0.05, 0.025, or 0.01 unit increments)dosing (0.05, 0.025, or 0.01 unit increments) Lock outLock out Worn between shoulder bladesWorn between shoulder blades If a toddler likes to remove the If a toddler likes to remove the

infusion set, let them know what infusion set, let them know what comes out must go right back incomes out must go right back in

Help For Kids & TeensHelp For Kids & Teens

Growth spurtsGrowth spurts Dawn PhenomenonDawn Phenomenon Easy coverage of snacksEasy coverage of snacks TDD and bolus history can be checked TDD and bolus history can be checked

to ensure consistent dosingto ensure consistent dosing Faster adjustment of basals and boluses Faster adjustment of basals and boluses

for changes in activity, etcfor changes in activity, etc

Special Teen ConcernsSpecial Teen Concerns

DatingDating Wearing, sharingWearing, sharing AlcoholAlcohol Eating disordersEating disorders Fast foodsFast foods FabricationFabrication Sleeping-inSleeping-in

Personal EffortPersonal Effort

Those who expect a pump Those who expect a pump to manage their diabetes to manage their diabetes

for them will fail to for them will fail to optimize their own optimize their own

therapy.therapy.

Learn how to adjust your basals and boluses for an excellent A1c!

First Steps Toward A PumpFirst Steps Toward A Pump

Keep detailed recordsKeep detailed records Consider your (and your child’s) motivationConsider your (and your child’s) motivation

Peer group, acceptance issues, family supportPeer group, acceptance issues, family support

Look at available pumpsLook at available pumps Which pump(s) does your insurance cover?Which pump(s) does your insurance cover? Talk with your doctor about a prescriptionTalk with your doctor about a prescription Visit a dietician to learn carb countingVisit a dietician to learn carb counting

What To LearnWhat To Learn

How your pump worksHow your pump works How to count carbs How to count carbs How to interpret BG results How to interpret BG results

and see BG patterns and see BG patterns When to increase and When to increase and

decrease basals and boluses decrease basals and boluses How to adjust for high GI foods, extra How to adjust for high GI foods, extra

activityactivity

How ToHow ToChoose A PumpChoose A Pump

Pump CompaniesPump Companies

Who sell or plan to sell Who sell or plan to sell pumps in the US:pumps in the US:

Animas R1200 Animas R1200 Dana Diabecare IIIDana Diabecare III Deltec CozmoDeltec Cozmo Medtronic Paradigm Medtronic Paradigm Nipro AmigoNipro Amigo Roche/DisetronicRoche/Disetronic

Visit www.diabetesnet.com/diabetes_technology/

Things To ConsiderThings To Consider

Look, feel, colorLook, feel, color Features: reminders, child block, waterproofingFeatures: reminders, child block, waterproofing Size of basal and bolus incrementsSize of basal and bolus increments Infusion set choicesInfusion set choices Safety and reliabilitySafety and reliability Customer supportCustomer support History History Ease of data analysisEase of data analysis Add-ons: meters, covers, casesAdd-ons: meters, covers, cases

Today’s Smart PumpsToday’s Smart Pumps

Easy dose calculations with Carb Factor Easy dose calculations with Carb Factor and Correction Factorand Correction Factor

Precise insulin dosing (0.05 units or better) Precise insulin dosing (0.05 units or better) to allow basal rates to be set up for Dawn to allow basal rates to be set up for Dawn Phenomenon, etc.Phenomenon, etc.

Tracks BOB to avoid insulin stackingTracks BOB to avoid insulin stacking RemindersReminders

Today’s PumpsToday’s Pumps

When control is poor or varies greatly on When control is poor or varies greatly on one of today’s pumps, the pump settings one of today’s pumps, the pump settings are incorrect.are incorrect.

Test and reset basal rates, carb and Test and reset basal rates, carb and correction factors until you have good correction factors until you have good control.control.

Garbage in…..Garbage in…..

How To Choose How To Choose An Infusion SetAn Infusion Set

Infusion SetsInfusion Sets Straight-In Teflon: Cleo, Inset, Straight-In Teflon: Cleo, Inset, Ultraflex, Quik-SetUltraflex, Quik-Set

Easier to insert, variety of depths (6, 8, 9 mm)Easier to insert, variety of depths (6, 8, 9 mm) Angled Teflon Angled Teflon (Comfort, Tender, Easy, Silhouette):(Comfort, Tender, Easy, Silhouette):

Fewer failuresFewer failures Insertion site is visible Insertion site is visible Longer is more secureLonger is more secure Adjust angle to reach fatAdjust angle to reach fat

Metal needles Metal needles (Rapid-D or bent needle)(Rapid-D or bent needle) As comfortable and often more reliableAs comfortable and often more reliable Very short, multi-needle infusion sets expected soonVery short, multi-needle infusion sets expected soon

Infusion Sets And InsertersInfusion Sets And Inserters

Smith’s Medical CleoSmith’s Medical Cleo

Medtronic Sil-serterMedtronic Sil-serter

Disetronic Rapid-DDisetronic Rapid-D

Animas InsetAnimas InsetQuik-serterQuik-serter

Site SuppliesSite Supplies Emla cream (Rx, 30 min wait) or ice cubeEmla cream (Rx, 30 min wait) or ice cube Set inserter: Cleo and Inset are self-contained, Set inserter: Cleo and Inset are self-contained,

ezSerter, Quick-Serter, Sil-Serter, Sof-SerterezSerter, Quick-Serter, Sil-Serter, Sof-Serter Adhesive: IV-3000, Hypafix, TegadermAdhesive: IV-3000, Hypafix, Tegaderm Stickies: Skin Tac-H, Skin PrepStickies: Skin Tac-H, Skin Prep Tape: Micropore, Durapore, Tape: Micropore, Durapore,

Band-Aid Blister Relief (wicking)Band-Aid Blister Relief (wicking) Sweating aid: Mastisol Spray Sweating aid: Mastisol Spray

(Detachol for removal), Skin Tac, (Detachol for removal), Skin Tac, Tincture of Benzoin, Skin PrepTincture of Benzoin, Skin Prep

Adhesive removal: Uni-Solve, AllkareAdhesive removal: Uni-Solve, Allkare

School SuppliesSchool Supplies Meter, lancets, test stripsMeter, lancets, test strips Glucagon, glucose tablets, or Glucagon, glucose tablets, or

crackers for lows crackers for lows Spare insulin, syringes or insulin pen Spare insulin, syringes or insulin pen Spare infusion set and pump batteriesSpare infusion set and pump batteries Ketostix or Precision Xtra to test for ketonesKetostix or Precision Xtra to test for ketones Information card with insulin-to-carb ratio, Information card with insulin-to-carb ratio,

formula for correctionsformula for corrections Telephone numbers of parents, health care Telephone numbers of parents, health care

providers, and pump manufacturer's help lineproviders, and pump manufacturer's help line

How To StartHow To Start

Starting On A PumpStarting On A Pump

Everyone is nervousEveryone is nervous Read, read, readRead, read, read

• Pumping Insulin, Kids Insulin Pumps And You Pumping Insulin, Kids Insulin Pumps And You (Animas), (Animas), www.childrenwithdiabetes.comwww.childrenwithdiabetes.com, , www.pumps4kids.cawww.pumps4kids.ca, etc, etc, etc, etc

Do lots of recording before and after startDo lots of recording before and after start Start to play with pump as soon as it arrivesStart to play with pump as soon as it arrives Saline practice helpsSaline practice helps Get telephone contacts: MD, CDE, pump Get telephone contacts: MD, CDE, pump

company, pump rep, other parentscompany, pump rep, other parents

Helpful Attitudes And HabitsHelpful Attitudes And Habits

Be blatant about your diabetesBe blatant about your diabetes A pump is a tool, not a cureA pump is a tool, not a cure Take a bolus for every biteTake a bolus for every bite Change site as directedChange site as directed Look for a solution for every problemLook for a solution for every problem Write down a reason for every low and highWrite down a reason for every low and high Test oftenTest often

John’s Pump RulesJohn’s Pump Rules

• Total Daily Dose = weight in lbs / 4Total Daily Dose = weight in lbs / 4

• Basal Dose = 50% to 60% of TDDBasal Dose = 50% to 60% of TDD

• Carb Factor = 500 / TDDCarb Factor = 500 / TDD

• Correction Factor = 2000 / TDDCorrection Factor = 2000 / TDD

• BG target = 90 to 120 mg/dlBG target = 90 to 120 mg/dl

• Basal target = +/- 30 mg/dlBasal target = +/- 30 mg/dl

• BOB = 20% per hourBOB = 20% per hour

• Correction boluses = < 8% of TDDCorrection boluses = < 8% of TDD

J Walsh and R Roberts: Pumping Insulin, 2005

Starting Insulin DosesStarting Insulin Doses

J Walsh and R Roberts: Pumping Insulin, 2005

Carb Counting And Recording Carb Counting And Recording As Ways To Lower The A1cAs Ways To Lower The A1c

Steps For A Better A1cSteps For A Better A1c

Carb counting – 0.6%Carb counting – 0.6% Givivg boluses based on an accurate carb count Givivg boluses based on an accurate carb count

– 0.3%– 0.3% Recording test results, carb intake, insulin Recording test results, carb intake, insulin

doses, & activity – 0.5%doses, & activity – 0.5%

Monitoring often – 0.5-2.0% Monitoring often – 0.5-2.0% Bolusing often – 0.5-2.0%Bolusing often – 0.5-2.0% Contacting your doctor or adjusting your own Contacting your doctor or adjusting your own

doses when you encounter unwanted BGsdoses when you encounter unwanted BGs

Carb CountingCarb Counting

Allows precise matching of carbs with Allows precise matching of carbs with bolusesboluses

Glycemic index, saturated fat, and high Glycemic index, saturated fat, and high protein all play a role, but grams of carb is protein all play a role, but grams of carb is what controls the blood sugar after a mealwhat controls the blood sugar after a meal

Easy!Easy!

Where Carbs Come FromWhere Carbs Come From

fruit/fruit juicefruit/fruit juice breads/bagelsbreads/bagels cerealscereals crackerscrackers grainsgrains muffinsmuffins ricerice potatoes/yamspotatoes/yams vegetablesvegetables

1 gram of carb

raises the BG

4 to 7 points!

dessert/cookies/cake/piedessert/cookies/cake/pie ice cream/frozen dessertice cream/frozen dessert sweetened beveragessweetened beverages milk/yogurt (not cheese)milk/yogurt (not cheese) beer/winebeer/wine honey/syrup/molasseshoney/syrup/molasses jams/jellys/preservesjams/jellys/preserves -ose foods like sucrose -ose foods like sucrose

(table sugar)(table sugar)

How To Count CarbsHow To Count Carbs

Food labelsFood labels Check portion sizeCheck portion size

BooksBooks Dr’s Pocket Guide, Health ChequesDr’s Pocket Guide, Health Cheques

A gram scale plus carb factorsA gram scale plus carb factors Carb factors are available in Pumping Carb factors are available in Pumping

Insulin and are built into scales like the Insulin and are built into scales like the Salter computer gram scaleSalter computer gram scale

Blood Sugar Testing – 1921Blood Sugar Testing – 1921

Blood Sugar Testing – 2004Blood Sugar Testing – 2004

Blood Sugar Testing – 2004Blood Sugar Testing – 2004

“I just don't write down (log) anything. I hate to take the time to do it. I'd rather have a machine talk for me. I think it revolves around partial general laziness, as well as the constant reminder of being different from everyone else. I know other diabetics who won't even test when they're out with friends. They hate ….”

The Artiste 6/28/04

Smart Charts

Needed to solve Needed to solve problemsproblems

Basis for better Basis for better diabetes health carediabetes health care

~0.5% drop in A1c~0.5% drop in A1cBlood sugar, insulin, food, activity, stress

Charting Improves ControlCharting Improves Control

Better Charts, Better A1cBetter Charts, Better A1c

ChartsCharts My Other CheckBookMy Other CheckBook

SoftwareSoftware Meter companiesMeter companies Internet: myhealthchannel.comInternet: myhealthchannel.com Pump Control SoftwarePump Control Software

Meters, PDAs & PumpsMeters, PDAs & Pumps Pump: Deltec, Disetronic, Animas, MedtronicPump: Deltec, Disetronic, Animas, Medtronic Meter: BD, Therasense, Lifescan, BoerhingerMeter: BD, Therasense, Lifescan, Boerhinger

Analyze Carb BolusesAnalyze Carb Boluses

1. Count carbs

2. Give carb bolus

3. Eat

4. Record BGs

5. Analyze BGs

6. Balance better next time

Match Your Carbs With BolusesMatch Your Carbs With Boluses

Accounts for Accounts for HALFHALF the day’s control! the day’s control! Keeps blood sugar normal after mealsKeeps blood sugar normal after meals Requires accurate carb counting and an Requires accurate carb counting and an

accurate carb factoraccurate carb factor 500 Rule provides a close estimate of 500 Rule provides a close estimate of

carb factor if the TDD is accuratecarb factor if the TDD is accurate

500 Rule To Find Carb Factor500 Rule To Find Carb Factor

Gives grams of carb covered by one unit of Gives grams of carb covered by one unit of Humalog or NovologHumalog or Novolog

500 / TDD = 500 / TDD = grams of carb per unit of insulingrams of carb per unit of insulin Example:Example:

Person’s TDD = 50 unitsPerson’s TDD = 50 units 500/50 = 500/50 = 10 grams of carb10 grams of carb covered by covered by

1 unit of Humalog or Novolog 1 unit of Humalog or Novolog Postmeal readings stay normal!Postmeal readings stay normal!

2000 Rule To Find Correction Factor 2000 Rule To Find Correction Factor

Gives how far your blood glucose is likely to fall per Gives how far your blood glucose is likely to fall per unit of insulin over 5 hoursunit of insulin over 5 hours

2000 / TDD = 2000 / TDD = # mg/dl your BG will fall per unit# mg/dl your BG will fall per unit

Example:Example: Person’s TDD = 25 unitsPerson’s TDD = 25 units 2000/25 = an 2000/25 = an 80 mg/dl drop80 mg/dl drop per unit of H or Nov per unit of H or Nov

Adapted from 1500 Rule by Dr. Paul Davidson, Atlanta, GAAdapted from 1500 Rule by Dr. Paul Davidson, Atlanta, GA

2000 Rule2000 RuleTotal Daily Dose Point drop per unit

20 units 90 pts 25 units 72 pts 30 units 60 pts 35 units 51 pts 40 units 45 pts 50 units 36 pts 60 units 30 pts 75 units 24 pts

1600, 1800, 2000, or 2200 may be divided by TDD to get point drop per unit

1800 provides a good average --- 1600 Rule is more aggressive and gives more insulin, while a 2000 or 2200 Rule gives less insulin

New DevicesNew Devices

Data storage and downloadData storage and download Easy recording of BGs, Easy recording of BGs,

insulin, carbs, activityinsulin, carbs, activity Automatic carb countingAutomatic carb counting Pattern recognitionPattern recognition Insulin dose guidanceInsulin dose guidance Data analysis to improve control Data analysis to improve control Feedback that encourages useFeedback that encourages use

Pump — Meter CombosPump — Meter Combos

CozMonitor from Deltec CozMonitor from Deltec and Therasenseand Therasense

Disetronic and Roche Disetronic and Roche Medtronic 512 and BD Medtronic 512 and BD

Paradigm LinkParadigm Link Animas and LifescanAnimas and Lifescan Dana Diabecare III and Dana Diabecare III and

Dana meterDana meter

TroubleshootingTroubleshooting

Most Pump Problems Occur InMost Pump Problems Occur In

First weekFirst week First monthFirst month First 6 monthsFirst 6 months

Problems are most likely when unexpected or inconvenient

Occasional Pump ProblemsOccasional Pump Problems

Setup tipsSetup tips LeaksLeaks

O-ringsO-rings HubHub LineLine

ClogsClogs Site infections Site infections

and abscessesand abscesses

AllergiesAllergies BleedingBleeding

onto skinonto skin inside needleinside needle under skinunder skin

Pump bumpsPump bumps HypertrophyHypertrophy DKADKA

Some frustration at times is normal!

Set And Site IssuesSet And Site Issues

Dislodged infusion setDislodged infusion set TunnellingTunnelling

Rapid-D and slanted Teflon sets Rapid-D and slanted Teflon sets work better for mobile kidswork better for mobile kids

Metal may be better than teflonMetal may be better than teflon InfectionInfection HematomaHematoma

Site PreparationSite Preparation

Prevents pump bumps, infection, and Prevents pump bumps, infection, and abscessabscess

StepsSteps Wash the handsWash the hands Sterilize the skin – IV PrepSterilize the skin – IV Prep Use bio-occlusive adhesive – IV 3000Use bio-occlusive adhesive – IV 3000 Insert the setInsert the set Use safety tapeUse safety tape

Will Your Pump Alarm?Will Your Pump Alarm?

Low batteryLow battery

Mechanical problemMechanical problem

Empty reservoirEmpty reservoir

ClogClog

Forgotten bolusForgotten bolus

LeakLeak

BleedingBleeding

Bad programmingBad programming

Dislodged infusion setDislodged infusion set

YesYesYesYesYesNoNoNoNo

How To Check Mechanical ProblemsHow To Check Mechanical Problems

Check from Check from

skin to pump:skin to pump:

Skin and siteInfusion setConnectionLineHubReservoirPump

High BG ChecklistHigh BG Checklist

See a leak or smell insulin?See a leak or smell insulin? Infusion set in place? Infusion set in place? Was infusion set primed?Was infusion set primed? Are connections at hub and O-rings tight? Are connections at hub and O-rings tight? Bubbles in the tubing? One inch = a half unitBubbles in the tubing? One inch = a half unit Clog in line? Clog in line? Alarms? Errors?Alarms? Errors?

If no cause is found, replace everything!

Test for all BGs over 300Test for all BGs over 300 Always test when nauseousAlways test when nauseous Test urine with KetodiastixTest urine with Ketodiastix Test blood with Precision Xtra meterTest blood with Precision Xtra meter

Earlier detectionEarlier detection No need to collect urineNo need to collect urine Keep currently dated strips availableKeep currently dated strips available

Go to ER at 1Go to ER at 1stst sign of vomiting! sign of vomiting!

Check Ketones EarlyCheck Ketones Early

More Insulin For More Insulin For Unexplained High BGsUnexplained High BGs

When a blood glucose test is unexpectedly When a blood glucose test is unexpectedly high, the correction bolus needed to lower high, the correction bolus needed to lower this will be much higher than normally this will be much higher than normally requiredrequired Loss of basal insulin delivery for several hoursLoss of basal insulin delivery for several hours Insulin resistance from length of Insulin resistance from length of

hyperglycemiahyperglycemia Insulin resistance from presence of ketonesInsulin resistance from presence of ketones

ConclusionConclusion A pump offers the latest A pump offers the latest

technology for precise insulin technology for precise insulin deliverydelivery

Requires commitment and Requires commitment and responsibilityresponsibility

Benefits include more flexibility, Benefits include more flexibility, less hypoglycemia, improved less hypoglycemia, improved control, and a longer, healthier control, and a longer, healthier lifespanlifespan

Make the commitment and start Make the commitment and start pumping!pumping!

QuestionsQuestions??????