INSULIN INFUSION PUMP Seminar by;

Vemula Praveen Kumar M.pharmacy II semester (Pharmaceutics)

University College of Pharmaceutical Sciences, Kakatiya University, Warangal.

CONTENTS

Introduction to insulin infusion pumps (pump) How to choose a pump and infusion set Working of pump Use of pump Formulas that help Site & site supplies Advantages &disadvantages with pumps Problems with pump & site Helpful habits & attributes Conclusion References

About insulin

Insulin is a hormone, normally produced by pancreas

Low levels of insulin (basal insulin) are required to block the uncontrolled breakdown of fats and glycogen into energy substrates for the body

High levels of insulin(bolus insulin) stimulate the storage of sugar in muscle and fat.

Insulin Infusion Pump

Insulin infusion Pump (IIP) is an external battery-powered device that delivers insulin at regularly scheduled intervals, day and night (through a short, flexible plastic tube inserted just under the skin), into the body at a programmed rate

to control blood sugars

Insu

lin E

ffe

ct

B DL

Endogenous insulin

Three Injection Regimen

R/Lispro/Aspart

Ultralente

Insulin release pattern

Insu

lin E

ffe

ct

B DL

Endogenous insulin

CSII or IIP

Insulin release pattern

Continuous delivery through the IIP, more closely mimics the natural secretion of insulin from the pancreas.

Insulin Infusion Pumps

Fairly recent technology.Generally fairly easy to use.Requires close patient involvement.More thinking and monitoring than insulin by

syringe.3,00,000 users worldwide.Operation is very simple, because the interface

is similar to a cell phone keypad.

Where Pumps Began

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

The Auto syringe AS2C and Harvard Apparatus Mill Hill Infuser were first

Single basal, no memory 50 ml syringe on pump exterior

1978 Autosyringe AS2C –>

1977BloodGlucose Meter

Block Diagram of IIP

When To Consider A Pump

More than 3 injections per day Tired of multiple injections Frequent or severe hypoglycemia Hypoglycemia unawareness DKA hospital admission Require small, precise doses Less risk of complications

Terms

# Basal Rate: that which is flowing between meals or boluses

# Bolus: sudden increase such as to adjust for a meal or abnormal sugar

# Suspend: to stop the basal rate for some time

# Infusion set: the cannula and tubing that goes from pump to skin and SQ tissue

Types of Pump

Open loop: User gathers sugar data and adjusts flow rates for activity, diet, other changes in sugar

Closed loop: The device checks sugar and adjusts insulin infusion

Pumps use short acting insulin Disappears faster Acts faster, so adjustments made faster

First Steps Toward A Pump

Keep detailed records Consider your (and your child’s) motivation Acceptance issues, family support Look at available pumps

Which pump(s) does your insurance cover? How your pump works When to increase and decrease basals and

boluses How to adjust for high GI foods, extra activity

Things To Consider while selecting a pump

Look, feel, colorFeatures: reminders, child block, waterproofingSize of basal and bolus incrementsInfusion set choicesSafetyCustomer supportHistory Ease of data analysisAdd-ons: meters, covers

Pump Companies

Animas R1200 Dana Diabecare III

Deltec Cozmo Medtronic Paradigm

Nipro Amigo Roche/Disetronic

Working of IIP The pump is programmed to deliver a constant

background rate of insulin called a basal rate, which may change at various times during the day, to closely match the individual’s needs.

Typically, the basal rate does not need to be changed often, once the person’s blood glucose patterns are known.

There may be some variation due to changing sleep / wake schedules or monthly hormonal changes.

These changes can be accommodated quite easily with the pump and therefore achieve better blood sugar control than insulin injections

Working of IIP

A lead screw and nut (describes as a “drive rod”) that would compress the syringe to inject the insulin.

The lead screw pushes down on the drive rod, which is actually a complex machined plastic plunger.

The precision fit of the lead screw and nut not only ensures the proper performance of the pump, it creates sealing features that help maintain a strict separation between the medication and the pump parts.

Before IIP UsingBefore IIP Using Everyone is nervousEveryone is nervous Read, read, readRead, read, read Pumping Insulin, Kids Insulin Pumps And Pumping Insulin, Kids Insulin Pumps And

You (Animas), and information booklets, You (Animas), and information booklets, visit websitesvisit websites

www.myomnipod.comwww.myomnipod.com www.minimed.comwww.minimed.com etc, etc ... etc, etc ...

Do lots of recording before and after Do lots of recording before and after startstart

Start to play with pump as soon as it Start to play with pump as soon as it arrivesarrives

Get telephone contacts: MD, CDE, pump Get telephone contacts: MD, CDE, pump company, pump rep.company, pump rep.

IIP sites & Site Preparation

Prevents pump bumps, infection, and abscess

StepsWash the handsSterilize the skin – IV PrepUse bio-occlusive adhesive – IV 3000Insert the setUse safety tape

IIP sites

Site SuppliesSite Supplies

► Emla cream (Rx, 30 min wait) or ice cubeEmla cream (Rx, 30 min wait) or ice cube► Set inserter: ezSerter, Quick-Serter, Sil-Serter, Sof-Set inserter: ezSerter, Quick-Serter, Sil-Serter, Sof-

SerterSerter► Adhesive: IV-3000, Hypafix, TegadermAdhesive: IV-3000, Hypafix, Tegaderm► Tape: Micropore, Durapore, Band-Aid Blister Relief Tape: Micropore, Durapore, Band-Aid Blister Relief

(wicking)(wicking)

► Sweating aid: Mastisol Spray (Detachol for removal), Sweating aid: Mastisol Spray (Detachol for removal), Skin Tac, Tincture of Benzoin, Skin PrepSkin Tac, Tincture of Benzoin, Skin Prep

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

Use of IIPUse of IIP

The tube and needle are referred to as an “infusion set.”The tube and needle are referred to as an “infusion set.”

Infusion sets Infusion sets Straight-In Teflon: Cleo, Inset, Ultra flex, Quik-SetStraight-In Teflon: Cleo, Inset, Ultra flex, Quik-Set Easier to insert at variety of depths (6, 8, 9 mm)Easier to insert at variety of depths (6, 8, 9 mm)

Angled Teflon (Comfort, Tender, Easy):Angled Teflon (Comfort, Tender, Easy): Longer is more secureLonger is more secure Adjust angle to reach fatAdjust angle to reach fat

Metal needles (Rapid-D or bent needle)Metal needles (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 Disetronic Rapid-DDisetronic Rapid-D

Animas InsetAnimas Inset Quik-serterQuik-serter

Crab counting Carbohydrate counting is an effective way to control

insulin regimens by means of giving only enough insulin to cover the grams of carbohydrate ingested. With an insulin pump, you simply add up your carbohydrates ingested, and insert the number into the pump—just like a calculator.

The pump then figures out, based on your programmed ratio, how much insulin is needed to cover your carbohydrates

Allows precise matching of carbs with boluses Glycemic index, saturated fat, and high protein all

play a role, but grams of carb is what controls the blood sugar after a meal

Easy!

Carb Counting How To Count Carbs Food labels

Check portion size Books

Dr’s Pocket Guide, Health Cheques

Keeps blood sugar normal after meals

The formula for calculating a correction dose is as follows:

1. Add the total daily dose (include both basal and bolus amounts) and then divide 1,800 by that number. The result is the decrease in glucose (mg/dl) one would achieve with 1 unit of insulin as a correction dose.

1,800/Total Insulin Dose = Decrease in Glucose (mg/dl) per 1 unit of insulin (This is the “insulin sensitivity factor.”)

2. Calculate the number of units of insulin needed based on the current glucose level and planned carbohydrate intake. Patients should test their glucose levels 2–3 hours after delivering the bolus to assess the outcome.

Example: J.D. normally takes 30 units of insulin per day: 15 units as basal and

15 units as bolus (5 units with each meal) 1,800/30 = 60 (insulin sensitivity factor)

A correction dose of 1 unit of insulin would be expected to decrease the blood glucose by 60 mg/dl. Patients should be taught to use their insulin sensitivity factor (this can be modified to ± 25%), as follows:

Blood Glucose – Target/Sensitivity = Correction Dose

If the premeal glucose is 198 mg/dl (~ 90 mg/dl above the premeal target of 110 mg/dl), the patient would need to add 1.5 units of insulin to the bolus insulin dose.

(198 – 110)/60 = 1.5 units

J.D. would then add 1.5 units to his meal bolus dose to lower his glucose into his target range.

It is important to note that this is just a starting point that must be assessed with follow-up blood glucose readings after the correction bolus is given

500 Rule To Find Carb FactorGives grams of carb covered by one unit of Humalog or Novolog500 Rule provides a close estimate of carb factor if the TDD is accurate

500 / TDD = grams of carb per unit of insulinExample:Person’s TDD = 50 units500/50 = 10 grams of carb covered by 1

unit of Humalog or Novolog Post meal readings stay normal!

1 gram of carbraises the BG 4 to 7 points!

2000 Rule To Find Correction Factor Gives how far your blood glucose is likely to fall per unit of insulin

over 5 hours 2000 / TDD = # mg/dl your BG will fall per unit Example Person’s TDD = 25 units 2000/25 = an 80 mg/dl drop per unit of H or Nov

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

Total 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

• 1800 provides a good average -

• 1600 Rule is more aggressive and gives more insulin,

• while a 2000 or 2200 Rule gives less insulin

New Devices Data storage and download Easy recording of BGs, insulin, carbs Automatic carb counting Pattern recognition Insulin dose guidance Data analysis to improve control Feedback that encourages use

Pump — Meter CombosCozMonitor from Deltec and Therasense

Disetronic and Roche

Medtronic 512 and BD Paradigm Link

Animas and Life scan

Dana Diabecare III and Dana meter

Sensor-augmented pump consisting of a Guardian RT sensor (A), which is attached to a Minilink transmitter (B) and they communicate with an insulin infusion pump (C).

The Big Three Medtronic Minimed

Paradigm 508, 512 / 515*, 712 / 715* Animas Corp.

IR1000, IR1200*, IR1250* Smiths Medical

Deltec Cosmo*

“Smart” Pumps Insulin pump software will calculate

mealtime insulin (bolus) based on: Current blood glucose Carbohydrate content of the meal Previous bolus (time and size)

*smart pump technology

AdvantagesAdvantages► Precise doses, as small as 0.025 u, can be Precise doses, as small as 0.025 u, can be

givengiven► RemindersReminders► Little risk of infectionLittle risk of infection► 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► Family activities are no longer tied to one Family activities are no longer tied to one

person’s needsperson’s needs► Easier handling of illness, travel, or Easier handling of illness, travel, or

campingcamping

Insulin Infusion Pumps and Exercise:Insulin Infusion Pumps and Exercise:

► Normalize the glycemic and metabolic responses because Normalize the glycemic and metabolic responses because insulin levels can be easily increased, decreased, or insulin levels can be easily increased, decreased, or maintained at basal levels. maintained at basal levels.

► In anticipation of exercise, insulin bolus can be adjusted. In anticipation of exercise, insulin bolus can be adjusted.

► Self Blood Glucose Monitoring (SBGM) - important and helpful.Self Blood Glucose Monitoring (SBGM) - important and helpful.

Disadvantages of IIPDisadvantages of IIP

► 10-15 minute delay in onset of insulin action10-15 minute delay in onset of insulin action► Infusion site needs changing for every 3-4 days Infusion site needs changing for every 3-4 days ► Always wearing a device Always wearing a device ► Size of the infusion pump Size of the infusion pump ► Vulnerability to trauma or disruption at the infusion site Vulnerability to trauma or disruption at the infusion site

► Must be removed for water sportsMust be removed for water sports

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 infectionsSite infections

AllergiesAllergies BleedingBleeding

onto skinonto skin inside needleinside needle under skinunder skin

Pump bumpsPump bumps Dislodged infusion setDislodged infusion set

Some frustration at times is normal!

Will Your Pump Alarm?

Low battery Mechanical problem Empty reservoir Clog Forgotten bolus

Leak Bleeding Bad programming Dislodged infusion set

YesYesYesYesYes

NoNoNoNo

Pumps don’t detect: Disconnection Air in line Infection Leaks Abnormal tissue sites

Infusion Site Problems: Tissue abnormality

Redness / pain / heat Hard tissue / scarring Kinked cannula Old site Improper depth / too near muscle / wrong angle

Air in line Tube disconnected

Problems with Infusion Pumps

Out of insulin? Is the pump leaking? Is the connection between the tubing and the pump cartridge tight?

Is the hub connection cracked? Can you smell insulin anywhere? (hint: Insulin smells like Band Aids) Do the pump motor arms (MiniMed) or piston rod (Disetronic) move freely?

Stocking of IIP

Extra stock: Keep refrigerated (36° - 46°F). Discard after

expiration

Current bottle in use: can be used for ~30 days at room temp (59°- 68°F optimally, below 86°F)

Helpful Attitudes And Habits

Be blatant about your diabetes

A pump is a tool, not a cure

Take a bolus for every bite

Change site as directed

Look for a solution for every problem

BG Test often

Conclusion A pump offers the latest technology for precise

insulin delivery

"Making the insulin pump available to Medicare beneficiaries will improve the quality of their lives. The infusion pump offers them a choice to better control their condition so that they are more active and productive,"

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

Make the commitment and start pumping!

If you are diabetic & use and Make ur life

ReferencesReferences

► A Randomized Trial Comparing Continuous Subcutaneous Insulin A Randomized Trial Comparing Continuous Subcutaneous Insulin Infusion of Insulin Aspart Versus Insulin LisproInfusion of Insulin Aspart Versus Insulin Lispro, , DIABETES CARE, DIABETES CARE, VOLUME 31, NUMBER 2, FEBRUARY 2008VOLUME 31, NUMBER 2, FEBRUARY 2008

► Insulin pump use in pediatricsInsulin pump use in pediatrics, , DIABETES CARE, VOLUME 30, DIABETES CARE, VOLUME 30, NUMBER 6, JUNE 2007NUMBER 6, JUNE 2007

► Classification of Distinct Baseline Insulin Infusion Patterns in Classification of Distinct Baseline Insulin Infusion Patterns in Children and Adolescents With Type 1 Diabetes on Continuous Children and Adolescents With Type 1 Diabetes on Continuous Subcutaneous Insulin Infusion Therapy, DIABETES CARE, VOLUME Subcutaneous Insulin Infusion Therapy, DIABETES CARE, VOLUME 30, NUMBER 3, MARCH 2007 30, NUMBER 3, MARCH 2007

► Comparison of apolipoprotein B100 metabolism between Comparison of apolipoprotein B100 metabolism between continuous subcutaneous and intraperitoneal insulin therapy in continuous subcutaneous and intraperitoneal insulin therapy in Type 1 diabetes, Journal of Clinical Endocrinology & Metabolism. Type 1 diabetes, Journal of Clinical Endocrinology & Metabolism. published August 9, 2005 as doi:10.1210/jc.2005-0989published August 9, 2005 as doi:10.1210/jc.2005-0989

► Bret berner, Steven M.Dinh: Electornically Controllede Drug Bret berner, Steven M.Dinh: Electornically Controllede Drug Delivery.Delivery.

► Attia, N.; Jones, T.W.; Holcombe, J.; and Tamborlane, W.V.: Attia, N.; Jones, T.W.; Holcombe, J.; and Tamborlane, W.V.: “Comparison of human regular and lispro insulins after interruption “Comparison of human regular and lispro insulins after interruption of continuous subcutaneous insulin infusion and in the treatment of continuous subcutaneous insulin infusion and in the treatment of acutely decompensated IDDM”. of acutely decompensated IDDM”. Diabetes CareDiabetes Care, Vol. 21, No. 5: , Vol. 21, No. 5: pp. 817–21, 1998.pp. 817–21, 1998.

► Comparison of Quality of Life in Diabetics Using Insulin Injection Comparison of Quality of Life in Diabetics Using Insulin Injection Therapy versus Subcutaneous Insulin Infusion Therapy by Katie Therapy versus Subcutaneous Insulin Infusion Therapy by Katie Michele Reynolds et al 2007 Ypsilanti, MichiganMichele Reynolds et al 2007 Ypsilanti, Michigan

ReferencesReferences

► McCall A. In: McCall A. In: Insulin TherapyInsulin Therapy. Leahy J, Cefalu W, eds. New York, . Leahy J, Cefalu W, eds. New York, NY: Marcel Dekker, Inc; 2002:193NY: Marcel Dekker, Inc; 2002:193

► Jay S. Skyler, MD, MACP; Steven Ponder, MD, FAAP, CDE Jay S. Skyler, MD, MACP; Steven Ponder, MD, FAAP, CDE Is Is There a Place for Insulin Pump Therapy in Your Practice? Volume 25, There a Place for Insulin Pump Therapy in Your Practice? Volume 25, Number 2, 2007 • CLINICAL DIABETESNumber 2, 2007 • CLINICAL DIABETES

► www.delteccozmo.comwww.delteccozmo.com► www.diabeticcare.comwww.diabeticcare.com► www.childrenwithdiabetes.comwww.childrenwithdiabetes.com► www.diabetesnet.comwww.diabetesnet.com► www.animascorp.comwww.animascorp.com► www.myomnipod.comwww.myomnipod.com► www.minimed.comwww.minimed.com