Pink Panther - Diabetes Management - Chapter 26

TOPICS:Medications(Insulin DeliverySystems)Prevent, Detectand TreatChronicComplicationsThrough RiskReductionTEACHING OBJECTIVES:1. Introduce basic pump concepts

including basal and bolusinsulin dosing.

2. Discuss advantages anddisadvantages of insulin pumptherapy.

3. Review risk factors resulting inhypo/hyperglycemia in pumpusers.

4. Explain pump options duringexercise (disconnect, reducebasal/boluses).

LEARNING OBJECTIVES:Learner (Parents, child, relative orself) will be able to:1. Differentiate between basal and

bolus insulin doses.2. Cite two advantages and two

disadvantages of insulin pumptherapy.

3. Identify two causes of low andof high blood sugars in pumpusers.

4. Identify two possible uses of atemporary-basal rate.

Chapter 26

Insulin Pumps

H. Peter Chase, MDSusie Owen, RN, CDEJana Gaston, RDJen Block, RN, CDE

INTRODUCTIONThis chapter is somewhat complex and does not need to be

read until the family is ready to consider insulin pump therapy.The chapter is not meant to teach everything one needs toknow about insulin pumps. There are entire books (see end ofthe chapter) written about pump therapy, and this chapter isonly meant to provide an overview. An insulin pump is amicrocomputer (the size of a pager) that constantly providesinsulin. When an insulin pump is used, insulin is first put into aspecial syringe which is then placed within the pump case. Asmall plastic tube called a cannula is then inserted under theskin with a needle (the needle is then removed, leaving theplastic tube in place). The cannula is connected to the pumpby a small tube. Insulin is infused through the small plasticcannula under the skin (most commonly placed in theabdomen or buttock). Tape is placed over the cannula set tokeep it in place for up to three days.

Pump management involves a high level of diabetes care. Itrequires a commitment by the entire family to help with the dailymanagement. No matter what age a person begins pump therapythey will need assistance to ensure safety and a positive outcome.Pump management needs to begin during a time when the familycan focus on developing new knowledge and skills.

It is important to realize that the current insulin pumps donot vary the insulin dose based on the blood sugar level. Thepump is programmed to give a pre-set amount of insulin at

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280 Chapter 26 Insulin Pumps

regular intervals (called the basal rate). Thebasal rates do not automatically change as bloodsugars change. In addition, each time the personeats or if the blood sugar is elevated, buttons onthe pump must be pushed to give a bolusinsulin dose. The smart pumps (explainedbelow) help to calculate the amount of insulinthe person should give. However, there is not aclosed-loop pump at this time that measuresblood sugars and turns off the basal insulin if theblood sugar is low or gives more insulin if theblood sugar is high. This will likely becomepossible at some time in the future.

Pump therapy is usually begun afterestablishing regular care with the healthcareteam over a six month period or more. Extravisits and trainings are generally required tobegin treatment with an insulin pump. A nurseeducator, social worker, dietitian and physicianusually spend about 3-4 hours with the personand family in a routine clinic visit deciding as ateam if a pump is the right choice. If it isdecided to proceed, the family may then attendthe Pump Basics and Pump Initiation classes.These classes are to prepare the families forpump therapy. This is often the time when thebrand of pump is selected. There are a total ofthree pump training classes each person attendsonce they have their pump, a saline class, aninsulin class, and an advanced pump trainingclass. The pump trainer and physician spendfour hours at the time of starting saline in thepump and then another 2-3 hours at the timeof starting insulin in the pump. The AdvancedPump Training class occurs about one monthafter starting the pump (see Post-pump Visits inthis chapter).

There is not a best age to begin using aninsulin pump. The time is right when theperson with diabetes and their family are readyand willing. It must not be the parents whowant and are pushing for the pump. The abilityto count carbohydrates and to reliably calculateand give an insulin dose is an obvious need.Younger children who cannot countcarbohydrates or reliably give a bolus insulindose must be considered on an individual basis.

The availability of a parent becomes a majorfactor when putting younger children on apump. No matter at what age a person beginspump treatment, assistance will be needed whenthe person is ill, depressed or shows a lack ofconsistent follow-through with daily tasks.

ADVANTAGES OF INSULIN PUMPS

Improved Glucose Control

The Diabetes Control and ComplicationsTrial (DCCT), as discussed in Chapter 14,showed that improved glucose control lessenedthe likelihood of the eye, kidney and nervecomplications of type 1 diabetes. Glucosecontrol is measured by doing a HbA1c test (seeChapter 14) every three months. Many peoplewho use pump therapy have some decrease intheir HbA1c values and thus decrease their riskfor complications. People who are not able tohave good sugar control on multiple dailyinjections of insulin may benefit from insulinpump therapy. Unfortunately, if insulin bolusesfor food or high sugar levels are missed, glucosecontrol will NOT improve and may worsen (seeDisadvantages below).

Insulin Delivery and Availability and Convenience

One of the big advantages of using a pumpis that the insulin is readily available. The pumpis attached to the person so if they are withfriends and are going to share a meal, theinsulin is available. It is relatively easy to push afew buttons to take extra insulin. The insulinpump is designed to deliver rapid-acting insulinin two ways:

1. A programmed basal rate (delivered in smallamounts every few minutes; see below)

2. A user-initiated bolus dose (a quick burst)of insulin with meals or with high bloodsugars (see below)

This is similar to the insulin output by thenormal human pancreas, with a constant (basal)

Chapter 26 Insulin Pumps 281

output of insulin and boluses of insulin withmeals. The pump has advantages over multipledaily shots in that insulin does not need to bedrawn from a vial and be injected. Youth, whofrequently do not like to take multiple shots, arethus more apt to cover random food intakewith a bolus of insulin. Only rapid-actinginsulin (Humalog, NovoLog or Apidra) is usedin the pump.

Hypoglycemia

Severe low blood sugars were three timesmore common in pump users or in peopletaking three or more shots per day (all usingRegular insulin) compared with peoplereceiving one or two shots of insulin per day inthe DCCT (see Chapter 14). Now, theexclusive use of rapid-acting insulins(Humalog/NovoLog/Apidra) with moretimely absorption, action and disappearance hasmade pumps safer in relation to hypoglycemia.Data shows that severe lows are now LESScommon for pumpers than for peoplereceiving twice daily NPH insulin injections.They are similar in number for those receivingLantus insulin.

Flexibility and Freedom

For some people, the use of a pumpprovides a greater opportunity for flexibility andfreedom.

Some of the ways in which this happens are:

4 being able to sleep late in the morning

4 the ability to alter the time or size of mealsor exercise

4 the ability to take extra insulin when theblood sugar is high or with illnesses (andhaving the insulin readily available)

4 being able to easily remove the pump forbaths, showers, heavy exercise, etc.

4 The long plastic tubing permits placementof the pump on the bedstand while sleepingat night. Several special holders areavailable for the pump.

4 Miss America (1999), Nicole Johnson, woreher pump strapped to her leg during theevening gown competition. She had theflexibility to disconnect the pump for theswimsuit competition.

Pumpers now have more flexibility sincethe basal insulin Lantus became available.Lantus is somewhat similar to the basal insulindose from the pump, and people can come offthe pump for a day, week, month or whateverand just take the same number of units ofLantus that they take for their pump basal dose(the total basal dose is given at the end of thebasal field on the pump screen). This is oftendone for people having a water day or week(e.g., Hawaii), during extreme sports or justwhen people need a break. It is important toremember to stay disconnected from the pumpuntil 24 hours after the last Lantus dose. Callyour care provider if you have questions.

Reduction of Blood Sugars After Mealsor Whenever High

With the rapid-acting insulins, the highblood sugars that occur after meals can bereduced using boluses prior to mealtime. Inaddition, extra doses of insulin are easy to takeif a high blood sugar is found between meals.This is discussed later under Correction InsulinDosages. The rapid-acting insulin in the pumpworks just like when it is given in shots. Itstarts to work in 10 minutes, peaks in 30-90minutes and lasts (effectively) three to fourhours. As carbs can raise the blood sugar in 10minutes, it should be obvious that, whenpossible, at least a part of the bolus should betaken prior to the first bite. Special bolussettings (square or extended wave, or adual wave) are available to help with thedelayed absorption found with high fat, highcarb meals such as pizza (see Advanced PumpTraining below).

Altering Insulin Dose with Exercise

It is easy to discontinue insulin delivery orto use a temporary basal for periods of exercise.The alterations can be made to fit the past


experience of the individual. Thus, somepeople decrease insulin 30 or 60 minutes priorto exercise, during the exercise, and/or forthree to seven hours after exercise (to preventdelayed hypoglycemia, Chapter 6). Similarindividualized alterations are more difficult withinjections.

DISADVANTAGES OFINSULIN PUMPS

Remembering to Bolus

Giving an insulin bolus with each meal orsnack that is greater than 5g of carbohydrate isdifficult for some people to remember. HbA1cvalues will not improve if boluses are forgottenand in fact they may rise. The basal dose turnsoff internal sugar production (Chapter 2). Itdoes not cover food eaten. There is nointermediate-acting insulin (e.g., NPH) to peakat a mealtime. If the bolus is forgotten, theblood sugar will rise quite high. In ourexperience, forgetting bolus doses is the majorreason for people not improving glucosecontrol when on a pump. It is our currentguesstimate that the HbA1c increases one-halfpoint if two meal boluses per week are missedfor three months. The increase will be by oneHbA1c point if four meal boluses per week aremissed for three months. Alarms in pumps,glucose meters or watches can help some peopleto remember to bolus. Receiving a reminderfrom another person can also be helpful. At thetime of the clinic visit, it is useful to downloadthe insulin pump to review bolus dosages given(or not given).

Ketonuria or Ketoacidosis

When problems occur with the insulinpump and insulin delivery is interrupted,ketones can develop quickly as there is no long-acting insulin in the body. Ketones will start toform in four hours (the duration of the lastHumalog/NovoLog/Apidra infused).Eventually, the alarm on a pump may sound if aline or catheter is plugged or if very little insulinis left in the pump. However, it is possible to

have a kinked tube that will deliver less insulin,or a break in the delivery system, or insulin thathas been spoiled by temperature extremes, thatwont set off an alarm. It may even be that thecannula has come out and the insulin is notbeing delivered under the skin. It is importantto realize that it may not be possible to tell byinspection that insulin is not being delivered. Ifthe blood sugar does not respond to a pumpcorrection or if more frequent urination orthirst is noted, pump users must do animmediate blood sugar, a ketone test, aninjection via a syringe and a change of theinfusion set, tubing and reservoir. In additionto having a new infusion set in place, correctioninsulin doses must be given by syringe or penuntil the blood sugar level has come down.

If sugar control has been good for a periodof time, ketones will generally not form asrapidly and/or can be cleared more easily. Incontrast, if glucose control has been poor, theketones will develop more rapidly and build up.In our experience, most pump users have timeswhen their catheter comes out, becomes kinkedor they experience other problems withdelivery. Insulin and syringes must be keptavailable in case they are needed for individualshots. Urine or blood ketone test strips (seeChapter 5) must always be readily available.Our pump families are routinely taught to usethe Precision Xtra blood ketone meter (Chapter5). This allows the family to know the exactketone status at that moment. Anytimeketones are present, correction doses mustbe given by syringe or pen, and the infusionset, tubing and reservoir must be changed.

Psychological Factors

Wearing a pump, even though it is notmuch bigger than a pager, is difficult for somepeople. We have heard the comment thatStarting the insulin pump was like gettingdiabetes all over again. People who had notknown that I had diabetes now ask me what thepump is. A considerable amount of learningabout the pump is necessary, which is not thatmuch different from the amount required whendiabetes was first diagnosed. There are other


feelings expressed such as constantly beinghooked to an instrument. (In contrast, asdiscussed earlier, some people like always havinginsulin with them.) The most important factoris often whether a method can be worked outto prevent missed insulin boluses.

Expense

Pumps are expensive but most insurancecompanies will now pay for at least a portion ofthe expense. Initial expenses include buying thepump (approximately $6,000 U.S.), starting thepump ($1,500-$10,000, depending on whetherthe pump start is done as an outpatient or inthe hospital) and yearly pump supplies (about$2,000). We do not do any pump starts in thehospital. Although this may seem like a lot, ifthe HbA1c level improves, the cost savings inthe prevention of eye, kidney and nervecomplications of diabetes offsets these expenses.

Weight Gain

Some people using insulin pumps who nowhave better sugar control may gain weight. Thesugar in the body is used rather than going outin the urine. The weight gain can happen inany person who improves their sugar control.Working with a dietitian before and afterstarting the pump can help to prevent this gain.In contrast, weight gain may be less of aproblem with the pump than with multipleinjections as it is not necessary to eat to keep upwith insulin previously injected. In our clinic,excessive weight gain for people using insulinpumps has not been a problem.

Skin Infections

Infections can occur at the infusion sites,particularly if the infusion sets are left in forlonger than three days. However, if propercleaning techniques are followed, and the set ischanged every two or three days, infections arenot common. If redness, heat, and/or pus arenoted at the insertion, the physician should becalled to get a prescription for antibiotics. Suchan area should not be used again as an infusionsite until it has healed.

Insulin Unavailability

One must remember to routinely fill theinsulin reservoir (syringe) in the pump so thatthe pump does not run out of insulin at anawkward time. Also, remember that insulinspoils if it freezes (unlikely next to the body) orreaches temperatures above 90. One of ourpatients cooked her insulin by wearing herwaterproof pump in a hot tub. Others havefrozen insulin by exposing tubing while skiing.This can be prevented by keeping the tubingclose to the body. Whenever the pump issubjected to temperature extremes or directsunlight the insulin may be compromised.

Infusion Site Locations

It is very common for a person withdiabetes to prefer certain locations for theirinjection sites. With the pump, it is importantthat all possible site locations be used, even theones that are not the favorites. A pump setcan be inserted anywhere an insulin injectionwould be given. Having several site possibilitieshelps to prevent hypertrophy in the sitelocations. Following a pattern of rotation andusing an infusion site template are alsohelpful to give each site maximum healing timebefore it is re-used.

STARTING THE PUMP:CLINIC VISITS AND PUMPTRAININGS

Pre-pump Visits

Insulin pumps are not for everyone.The person with diabetes (not just other familymembers) must be ready for the insulin pump,want the pump and be fully committed to usingthe pump. The visits and trainings below areusually required to initiate insulin pumpmanagement:

1. Initial Pre-pump (Routine Clinic) Visit

4 The person with diabetes and their familymeet with the physician, nurse, dietitian andsocial worker to discuss the basics and the


advantages and disadvantages of pumptherapy.

4 We request four or five blood sugars bedone per day, recorded and faxed to usweekly (often for one month). This gives usan idea of the commitment of the personand the family, as well as their reliability.The proof of blood sugar checking may alsobe required by the insurance company.

4 If the person is not already countingcarbohydrates, the dietitian will giveinstructions in this area. We usually ask thatpotential pump users (or their parents) beable to count carbohydrates. We also askthat they bring or send completed bloodsugar and food records, as well as insulindoses, to the dietitian.

4 A video on the pump and other informationis sent home with the family for review.Either the person or an adult must be ableto reliably give bolus dosages, and must beable to deal in tenths of units of insulin.

4 A dummy pump may be taped on to seehow the child tolerates it.

4 Further instruction with the dietitian aboutcarb counting is usually necessary.

4 The social worker is available to discussconcerns about starting the pump.

4 People who are ready for a pump:

l are willing to share with others that theyhave diabetes

l want the pump themselves and are notbeing pressured by others

l are willing to do frequent blood sugarmonitoring

l are either doing carb counting (Chapter12), are willing to learn, or have aparent who can do it for them

l are willing to use all possible injectionsites

2. Pump Basics and Pump InitiationClasses

Much of the basic information in thischapter is presented in these two classes.Families are shown the different brands ofpumps to help them make their selection.Families are asked to review this chaptertogether at home.

3. Saline Start Training

The person (and family) is trained to wearthe pump, program the pump and to doinfusion set changes.

4 We recommend that the instructional CD-ROM be viewed at least two times tobecome familiar with all of the basic pumpfunctions before the saline training.

4 The family must bring the pump, case,batteries and supplies for two or threeinsertions and reservoirs (in case needed).

4 Only sterile saline (salt water) is used in thepump. They discover if they are able to dothe required every two or three day infusionset changes. It is important to practiceusing the pump between the saline and theinsulin trainings to become comfortablewith how it works. The usual syringeinsulin injections continue while wearingthe pump with saline.

4 All technical aspects of the pump are taughtat the saline start.

4 The learning objectives from the beginningof this chapter are reviewed with thefamily(ies) to make sure they are learningthe essentials.

4 The person/family should bring significantothers who:

l may help with future pumpprogramming and/or problems

l may assist with blood sugar testing(particularly in the middle of the night)


4. Insulin-start Training and Visit (See Table 1)

a. The morning of the visit:

4 We ask that NO NPH OR LANTUSINSULIN be taken on the morning wheninsulin is started in the pump. The normaldose of rapid-acting insulin can be taken tocover breakfast prior to coming to the visit.If Lantus insulin is usually taken at dinner orin the evening, the person will be asked tojust take NPH insulin (or multiple shots ofrapid-acting insulin) the night beforestarting the pump. Individualinstructions are outlined inTable 1.

4 The person/family shouldbring significant others who:

l must be available tohelp with possiblehypoglycemia orhyperglycemia

l should review glucagonadministration

l will be assisting in the day-to-daymaintenance of the pump and infusionsites

The support of the significant other(s)helps with success in pump use.

b. The process:

4 The physician sets the initial basal insulindoses (see Insulin Delivery in this chapter).

4 The dietitian again reviews carb counting(Chapter 12) and the food records.

4 The nurse educator or pump trainerfinishes the technical training for theinsulin pump and teaches how totrouble shoot and maintaininfusion sites and pump.

4 It is important to review howto reduce the basal dosesusing the Temporary-BasalRate. The percent entered

into the pump is the percent of the usualbasal dose to be delivered. For example, ifthe usual basal rate is to 1.0 units per hour,and 70 percent is entered, 0.7 units perhour will be given. The time to use thetemporary basal rate must also be entered.

4 The social worker is available to discussconcerns or fears.

12:43

Food in mouth,hand on pump


Table 1Pre-Insulin Pump Start InstructionsName: _____________________ Saline Start Date: ________ Insulin Start Date: ________

The following instructions should be discussed at the saline pump start:

IF YOU ARE CURRENTLY ON N (NPH), or Lantus at dinner or in the evening, yourphysician recommends the following for the night before your insulin pump start (physicianto check all that apply):

nn Switch your evening dose of Lantus to N (NPH) and take _____ units of NPH (N) at_________ p.m.* (If on Lantus, usually about 40 percent of the Lantus dose is given as NPH.)

nn Do not take any long-acting insulin the evening before your pump start. Instead, supplementwith ______ units of rapid-acting insulin every ____ hours through the evening and night.

* If needed, get a prescription from your physician for Humulin or Novolin N (NPH).

If you are currently taking Lantus in the morning, you may take it the morning of the day beforeyour pump start. (Do not take it the morning of your insulin pump start!)

The night before the insulin pump start:

l Give the usual insulin dose at dinner of rapid-acting insulin and follow the directions prescribedabove for your other insulin. Eat a regular meal.

l Get all of your supplies (see below) organized to take to the clinic.

l Watch the pump instructional video or use the interactive computer software one more time.

l Read Chapter 26 on pumps in Understanding Diabetes once again.

The morning of the insulin pump start:

DO NOT give any N (NPH) or Lantus this a.m.

l Give the usual Humalog/NovoLog/Apidra dose with breakfast. Do not take any otherinsulins.

l Bring your pump and pump supplies, Humalog/NovoLog/Apidra insulin, blood sugar testingequipment, snacks and written materials with you to the clinic.

If you have any questions, please contact your healthcare provider.

__________________________________________ _________________ ______________________Physician Phone Date

__________________________________________ _________________ ______________________Nurse Phone Date

Remember, you must call or fax blood sugar records in daily for the first 1-2 weeks after yourpump start (see Table 4)! Discuss this with your physician or nurse at your insulin start.


INSULIN DELIVERY

Insulin Infusion Sets

We do not recommend one infusion set overanother. Every person is different and thefavored set varies from person-to-person. Someof the sets most frequently used at present areshown in Table 2. However, new sets arebecoming available all the time. For people whohave difficulty with needles, it is fine to useEMLA or LnMnX-4 cream. These are topicalanesthetic creams which would need to beapplied one hour before doing the insertion.The table indicates sets which have an automaticinserter. These devices push the needle andplastic tube through the skin, usually with thepush of a button. The needle is then removed,leaving the tube in the fatty layer under the skin.The typical cannula length for a child is aboutthe same length as the short needle syringes.

There are several tips to making infusionsets stick better. The first is to start with cleanskin (shaved if necessary). Many people thenapply Skin Prep or IV Prep to make the skinsticky (let it dry). Some then place a dressing(Tegaderm, IV-3000) directly on the skin andinsert the infusion set through the dressing. Asecond dressing can be placed on top of theinfusion set to sandwich it in place. If this isdone, a hole must be cut in the top dressing sothe set can be connected. Some people preferto just tape the set in place with medical tape(Transpore, Hypafix) or standard waterproofathletic tape. If the tape is irritating the skin, awipe-on skin barrier such as Cavilon may help.Also, Tincture of Benzoin, Mastisol or SkinBond can be applied to the skin before thetape or set and will work like glue. A medicaladhesive remover (Uni-Solve, Detachol) maythen be needed to remove the set and tape.

When possible, it is best to do the set changein the morning. This is because the person maybe more sensitive to insulin in the new (non-swollen) site. It also gives time to make sure theset is working well before going to bed. Manytimes with the typical busy family schedule, setchanges are not possible until later in the day.

The second best time to change the infusion setis after school and activities, but before dinner.Then if the set is not working properly, thefamily will know before bedtime. If it isnecessary to do a set change in the evening ornight it is essential that the blood sugar bechecked 2-3 hours later to make sure theinfusion set is working and to make certain theblood sugar is not low. Many families use atemporary basal setting (approximately 70percent) for the next 4-6 hours if the bloodsugar is not high prior to a nighttime set change.It is generally recommended that set changes bedone every two to three days. If blood sugarstend to routinely run high on the third day or ifthe weather has been hot, it may be necessary todo the set change after two days.

Methods of Delivery

The pump delivers insulin in three ways:

1. Basal Dosages

Basal dosages are programmed into thepump with the direction of the healthcareprovider and remain the same day-after-dayunless purposely changed. Table 3 can be usedto direct initial insulin pump doses.

The basal rate:

4 reflects the units of insulin per hour thatwould be needed to maintain a stable bloodsugar if a person were not eating meals

4 is similar to the small amount of insulinreleased by the pancreas every few minutesto turn off sugar production by the liver andto prevent fat breakdown

4 usually consists of 50-60 percent of the totaldaily pump insulin dose

The number one goal in the first week is tocalculate and fine-tune the desired basal dosages.

Dosing

In starting the insulin in the pump, theinstructions in Table 1 should be followed. Theinsulin dose for the pump is calculated bydifferent doctors in different ways. Sometimes


Table 2Pump Infusion Set OptionsYour doctor and your insulin pump trainer can help you choose the infusion set that will work the bestfor you. The variety has increased greatly and many new options are appearing on the market every fewmonths. Some of the most widely used infusion sets are listed below:

Cannula Lengths Tube Lengths Inserter or Sertable

Medtronic Mini-Med Paradigm PumpsParadigm Quick-Set 6mm or 9mm 23 and 43 yesParadigm Silhouette 17mm 23 and 43 yes

Medtronic Mini-Med (400 series 508 series pumps)Quick-Set 6mm or 9mm 23 and 43 yesSilhouette 17mm 23 and 43 yes

Deltec CozmoComfort 17mm 23, 31 and 43 noCleo90 6mm or 9mm 24, 31 and 42 yes

AnimasInset 6mm or 9mm 23 and 43 yes

*All but the Paradigm infusion sets have a luer lock end that will work with all non-Paradigm pumps.

the total insulin dose taken by shots in a day(rapid and long-acting insulin) is added and 70percent of this total is used.

Approximately half of the pump insulin isgiven as the basal insulin and half as boluses. Ifthe person is on Lantus insulin, the total basalinsulin per 24 hours is about the same as thedose of Lantus. Many doctors divide the dayinto parts (e.g., in three hour time periods: 12midnight to 3:00 a.m., 3:00 a.m. to 6:00 a.m.,etc.) and initially reduce the doses during thenight and give a bit extra after meals. (Thelatter is because most people do not bolusadequately to cover meals.) An example of theschedule we fill out is shown in Table 3.

4 The number of basal dosages to be usedvaries between doctors. Some start withone or two basal rates and others with 8-12basal rates

4 Many teenagers and young adults needmore insulin in the early morning hours tocover the bodys normal increase in growthhormone (the dawn phenomenon)

4 ALL people are different, and the use of

different basal doses allows for individualfine-tuning

4 Once the basal rates are set they tend to stayquite consistent

Some reasons to change basal rates are:

l large changes in body weight

l change of time zones (just change timeon pump)

l injuries

l some medications (e.g., steroids)

l temporary reductions for exercise

l temporary increases for menses

4 At a later date, basal rates can be checked byhaving the person not eat a meal. If thebasal rate is correctly set, the person will nothave a low (< 70 mg/dl [< 3.9 mmol/L])or high (> 200 mg/dl [> 11.1 mmol/L])sugar despite not having eaten. Skippingthe bedtime snack, fasting overnight andhaving a late breakfast while measuring theblood sugars every 2-3 hours is often thefirst basal test to do.


2. Bolus Dosages for Food:

4 These are taken before meals or snacks. Thebolus dose (or grams of carbs to be eaten)must be entered in by the user and activatedor it will not be given. All carbs should beentered into the new smart pumps and itwill indicate if a bolus should be given.

4 Approximately 40-50 percent of the dailypump insulin doses are given as bolusesbefore meals and snacks. At least a part ofthe bolus (for the correction and for food todefinitely be eaten) must be given prior tothe first bite. (Carbs raise blood sugar in 10minutes and Humalog/Novolog/Apidrabegin to work in 10 minutes.) Some peoplegive multiple small doses as they decide toeat more.

4 Everyone is different and boluses can bechosen to fit individual eating habits.

4 The dietitian is an important member of thepump team and will need to review andreinforce carb counting. Changes are oftensuggested in Insulin/Carb (I/C) ratios fordifferent meals after reviewing food records,insulin dosages taken and blood sugar levelstwo hours after meals.

4 Most families attend carb counting classesprior to starting insulin pump therapy.However, dosages sometimes change afterstarting the pump. This is because anintermediate-acting insulin (e.g., a.m. NPHacting at lunch time) is no longer peaking.Good record keeping in the period afterbeginning the pump is essential.

4 Some families bring food, insulin and bloodsugar records at the time of starting the pumpwhich help to set the initial I/C ratios.

4 The only way to know if an insulin dose forfood was correct is to do a blood sugar levelbefore and two hours and four hours afterthe meal. The ADA now recommends thatthe peak blood sugar be less than 180mg/dl (10.0 mmol/L) following a meal.Many care providers suggest the two-hourvalue after meals to be below 140 mg/dl(7.8 mmol/L). To test the I/C ratio, start

with the blood sugar in the target range andeat a low-fat microwavable meal with knowncarbs. (Excess fat delays stomach emptyingand prolongs sugar elevations.) Bloodglucose must be monitored as describedabove with the second hour and fourthhour tests. Most people use differentinsulin to carb (I/C) ratios for differentmeals. Thus a meal bolus test may need tobe tried at each meal time.

4 It is common for people to have differentI/C ratios for different times of the day,especially for bedtime snacks. This allowsfor a less aggressive I/C ratio to be usedat this time, thus lessening the chance fornighttime hypoglycemia.

4 The rule of 500 is sometimes used to helpcalculate I/C ratios. The total insulin perday (e.g., 50 units) is divided into 500. Forthis example (500 50 = 10), one unit ofinsulin would cover 10g of carbohydrate.

4 The new smart pumps can beprogrammed with I/C ratios for differenttimes of the day. Then when the grams ofcarbs to be eaten are entered in the pump,the units of insulin to take shows up on thescreen. This is particularly helpful forpeople not adept at math.

3. Bolus Dosages for Corrections

Extra (unscheduled) insulin boluses areimportant to use if the blood sugar level is high.These can be determined in one of several waysand, once again, it is best to try differentmethods and see what works. Remember thatlarger dosages will be required if ketones arepresent (and should be given by syringe orpen). The healthcare team should be contactedif moderate or large urine ketones or bloodketones > 1.0 mmol/L are found. There areseveral ways to calculate correction boluses.

An example of a correction bolus:

4 If a patient is using the correction factor ofone unit for every 50 mg/dl the glucose isabove 150 mg/dl, the 50 mg/dl is thesensitivity factor that says that one unit will


Table 3Insulin DosesName _______________________________________________ *Date___________________________

(*For insulin start)

Starting Basal Rate(s)Start Time Units per Hour Start Time Units per Hour

1. ________________ ______________________ 7. ________________ _______________________

2. ________________ ______________________ 8. ________________ _______________________

3. ________________ ______________________ 9. ________________ _______________________

4. ________________ ______________________ 10. ________________ _______________________

5. ________________ ______________________ 11. ________________ _______________________

6. ________________ ______________________ 12. ________________ _______________________

Total ______________________________________

Carb CountingStarting Bolus Dosages

Time Insulin/Carb Ratios Time Insulin/Carb Ratios

1. ________________ ______________________ 3. ________________ _______________________

2. ________________ ______________________ 4. ________________ _______________________

Insulin Sensitivity Ratio

Time 1 unit lowers BG by: Time 1 unit lowers BG by:

1. ________________ ________________ mg/dl 3. ________________ ________________ mg/dl

2. ________________ ________________ mg/dl 4. ________________ ________________ mg/dl

Target Blood Glucose Levels

Time Target BG Time Target BG

1. ________________ ______________________ 3. ________________ _______________________

2. ________________ ______________________ 4. ________________ _______________________

Duration of Insulin Action: _______ Hours

If you have any questions, please contact your healthcare provider:

MD: ______________________________________________ Phone: ___________________________

RN: _______________________________________________ Phone: ___________________________

Remember, you must call or fax blood sugar records in daily for the first 1-2 weeks after yourpump start (see Table 4). Discuss this with your MD or RN at your insulin start.


reduce the blood sugar 50 mg/dl and the150 mg/dl is the target blood sugar. If theblood sugar level was 300 mg/dl, threeunits of insulin would be the bolus amountused to bring the blood sugar to 150 mg/dl.(This was determined by subtracting 150from 300 = 150 and then dividing by 50 = 3units of insulin.) Most teens correct to 100mg/dl (5.5 mmol/L) during the daytimehours (e.g., 7 a.m. - 7 p.m.).

4 For people using mmol/L for glucose values,one unit of insulin for every 2.8 mmol/Labove 8.3 mmol/L could be used. For alevel of 16.7 mmol/L with a desire to reach8.3 mmol/L, divide 2.8 into 8.4 (16.7 minus8.3) and give three units of insulin.

4 The above calculation and a new bolus canbe repeated after two to three hours if theblood sugar is still high.

4 Many people now use one target blood sugarfor the day (e.g., correct to a glucose level of100 mg/dl [5.5 mmol/L]) and a second, lessaggressive target for during the night (e.g.,150 mg/dl [8.3 mmol/L]). It is helpful forthe less aggressive target blood sugar to begintwo to three hours before bedtime to lessenthe chance that the patient will have to treat a

blood sugar that has dropped below 100mg/dl right before bedtime.

4 With the newer smart pumps, when theblood sugar is entered or transmitted, thecorrection dose is suggested based on thecorrection factors already entered into thepump. The user then has the option toaccept or not accept the suggested dose.This may be particularly helpful for youngchildren. The smart pumps also calculatethe insulin remaining from the previousbolus and subtract that amount from thenext bolus.

4 The smart pumps will suggest a reduceddose when blood sugars are under the targetblood sugar and some food is being eaten.If the blood sugar is below 70 mg/dl (3.9mmol/L) the pump will not suggest a foodbolus. These adjustments are based off theblood sugar, the sensitivity factor, and thetarget blood sugar.

4 If a blood sugar during the day is high (>300 mg/dl [16.7 mmol/L]), an extra unitof insulin is often added to the bolus. Ifmoderate or large urine ketones or a bloodketone level > 1.0 mmol/L is present, thecorrection insulin dose is often doubled.


BLOOD SUGAR TESTINGMore frequent blood sugar testing is

required in the first week or two to help set thebasal rates. The levels to aim for are the sameas those shown for different ages in Chapter 7.

At a minimum:

4 tests should be done prior to each meal

4 before the bedtime snack

4 two hours after eating two or three mealseach day (to help adjust bolus doses)

4 once during the night (start at 12 midnightthe first night) and then test one hour later(e.g.: 1 a.m.) the second night and one hourlater in each succeeding night for one week

4 two hours after a correction dose

This amounts to seven or eight tests per day.This number may be reduced in the second weekto four or five per day. It is obvious that parentsor a significant other are extremely helpful at thistime to assist with testing. The minimum willeventually be four tests daily with occasionalchecks during the night; however, when strivingfor safe tight control, more than four bloodtests a day are usually needed. The form we likefor reporting (faxing or e-mailing) blood sugarresults is shown in Table 4 and may be copied asoften as desired. It can also be found on ourwebsite (www.barbaradaviscenter.org) for use ine-mailing blood sugars.

The person (or family member) faxes blood sugar results daily for the first week, then weekly for several weeks and then everytwo to four weeks. Good communication at thistime is essential.

Post-pump Visit (Advanced PumpTraining)

4 A food record may be brought to this visitto fine tune the insulin-to-carbohydrateratios with the dietitian. Other methods ofpreventing high blood sugars after meals(such as the square or extended wave ordual wave bolus) are discussed.

4 Sick-day management, site care andhypoglycemia are reviewed.

4 Sometimes a second set of basal doses isprogrammed into the pump for highexercise days (lower basals) or for menses(higher basals).

4 A physical exam is done including a carefuleye check at this time (particularly if theblood sugar control is rapidly improving).

ADVANCED PUMPTRAINING

Approximately one month after the insulinstart, families complete their training withAdvanced Pump Training. The followingactivities and topics are covered:

4 Any problems the person/family is havingwith the pump are addressed.

4 Programming and application of theadvanced features.

4 How to use the pump to adjust for exerciseand how to evaluate the effectiveness of theexercise adjustment. A second set of basaldoses may be programmed into the pump.

4 How to apply basal and bolus tests.

4 If the Sof-Set or Quick-Set is primarilybeing used, the Silhouette Infusion Set maybe demonstrated. The Silhouette set oftenstays in place better with heavy exercise.

4 Trouble shooting is reviewed for pump andblood sugar issues.

4 Special bolus features are introduced calledthe square or extended wave, or a dualwave. These allow a bolus to be given over aperiod of time (square and extended boluses)or with a portion of bolus given in the usualfashion and a portion as a square wave (dualwave). These special features are helpful formeals such as pizza or spaghetti, which arehigh in carbs and fat and cause prolongedsugar elevation (for some people).


Tab

le 4

W

eekl

y In

sulin

Pum

p M

anag

emen

t Rec

ord

Nam

e ___

____

____

____

____

____

____

____

____

____

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____

____

____

____

____

____

Day

& D

ate

12M

1A2A

3A4A

5A6A

7A8A

9A10

A11

A12

N1P

2P3P

4P5P

6P7P

8P9P

10P

11P

Not

esB

GC

arbs

Bas

alFo

odC

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nB

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arbs

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Bolus Bolus Bolus Bolus Bolus Bolus Bolus

Targ

et R

ange

:I/

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atio

I/C

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HYPOGLYCEMIACauses

The three main causes of low blood sugarsfor people using an insulin pump are all relatedto human (not pump) errors.

They are:

1. Too few blood sugars

Some people go through periods when theydo not do the extra required work of morefrequent blood sugar checking necessary forintensive diabetes management. They may be

having lows and not be aware this is happening.They may then have a severe hypoglycemic event.

2. Incorrect bolus dose

This may be because carbohydrate countingis not being done or because the personcalculated wrong. It can also happen when abolus is taken and a meal is then interrupted.

3. Wrong adjustment for exercise

Some people fail to think ahead and makeneeded changes in insulin dosage for exercise.At other times it may be a new exercise or one

Table 5Keys to Avoiding Lows

Always do AT LEAST four blood sugarsdaily (and occasional checks during thenight)

Count grams of carbs to be eaten (or justeaten) to give correct food bolus

Test before, during and after exercise

Recognize the symptoms of lows and treatpromptly

Think ahead regarding variations in dailyschedule which could result in low bloodsugars

If the blood sugar level is below 70 mg/dl(3.9 mmol/L) and it is time for a foodbolus dose, subtract one unit from thebolus amount

Reduce bedtime boluses for the bedtimesnack or boluses during the night by half(the reduction may vary for differentpeople)

Use a temporary (or alternate) basalpattern for heavy exercise and/or duringthe night after days of heavy exercise

Try not to do routine set changes afterdinner. The new area may be moresensitive to insulin increasing the chance ofhypoglycemia. A blood glucose test twohours after each set change is essential.


that is more intense than usual, and they justdid not realize how much it would lower theirblood sugar. The answer is to test blood sugarsbefore, during and after exercise and to haveextra drinks or food available.

Often a temporary basal is used duringexercise or during the night after a day with heavyexercise. If one enters 70 percent as a temporarybasal, 70 percent of the usual basal dose is given(not a 70 percent reduction). Others use adifferent basal setting (e.g., 0.2 u/hr lower) fordays of heavy exercise.

Symptoms of Hypoglycemia

The symptoms and treatment of low bloodsugar (hypoglycemia) are the same as those forpeople receiving insulin shots (Chapter 6).However, the symptoms may be somewhat lessobvious when the blood sugar levels fall slowlyover time from a mildly elevated level. Somekeys to avoiding lows are given in Table 5.

Additional symptoms which should alertpeople/families to think of hypoglycemia duringthe nighttime (Chapter 6) are:

4 inability to sleep or waking up alert

4 waking up sweating

4 waking up with a fast heart rate

4 waking up with a headache

4 waking up feeling foggy-headed or withmemory loss

IF ANY OF THESE DO OCCUR, DO ABLOOD SUGAR CHECK IMMEDIATELY.If low, treat appropriately and call the doctor ornurse the next day. A repeat blood sugar shouldbe done (to make sure the blood sugar is backup) prior to again falling asleep. Also thinkabout what was different the previous day (extraexercise, bolus insulin, less food, etc.). This willallow planning ahead to prevent the low with asimilar occurrence in the future. If you havequestions, call your doctor or nurse. A summaryof some key ideas for avoiding lows is given inTable 5.

Treatment of Hypoglycemia

If hypoglycemia is suspected, the person withdiabetes should be treated as described inChapter 6. If the blood sugar is below 60 mg/dl(3.3 mmol/L), we prefer 15g of quick-actingcarbohydrate first (four ounces of juice or sugarpop or four glucose tablets). If it is still below 60mg/dl (3.3 mmol/L) after 15 minutes, repeatthis treatment. When it is above 60 mg/dl (3.3mmol/L), give solid food.

If the glucose value is below 50 mg/dl (2.8mmol/L) or if the person is out of it orunconscious, the pump should be placed onsuspend or disconnected for a period of atleast 30 minutes. Others will set a temporarybasal of 0.0 units per hour for the next hour sothat the pump will restart without the personhaving to remember. A parent, teacher orsignificant other must know how to do this, asthe person with the low blood sugar may beconfused. It must be remembered that insulinalready infused will not yet have peaked, and sogiving the sugar is essential. Instant Glucose(or cake decorating gel) and glucagon must bereadily available for someone who knows howto give them (as for all people with diabetes).

HIGH BLOOD SUGARSNon-Pump Related Causes

Some of the causes of high blood sugars for pumpusers are the same as for people taking theirinsulin by shots:

4 extra food intake (without an extra bolus)

4 lack of exercise

4 forgetting boluses or giving after meals

4 illnesses/infections

4 hormones (stress, menses [many youngladies use a second basal setting which is 0.1or 0.2 u/hr higher during menses])

4 over-treating low blood sugars

4 spoiled insulin


In Addition, Failure to Deliver InsulinMay Occur

The most common causes of the pump notdelivering insulin are:

4 an empty reservoir (insulin syringe)

4 a clogged infusion set

4 leaks in the infusion set; a bead of insulinmay be noted or the scent of insulin may bedetected

4 an infusion set which has come out

4 a kinked cannula

4 a dead battery

If the blood sugar has not responded to acorrection bolus with the pump or if the bloodsugar is extremely high or if there are ketonespresent, the infusion set must be changed and asyringe shot correction given. If moderate orlarge urine ketones or a blood ketone level >1.0 mmol/L is present, the correction insulindose is often doubled. If a syringe correctionhas been given and the blood sugar does notrespond, the insulin used could be bad.

In order to prevent running out of insulin,the syringe should be filled every 2-3 days as

the set is changed. Table 6 summarizes somepossible pump problems. Remember that allpumps have a 1-800 number on the back to callfor help 24 hours a day.

EXERCISE (See Chapter 13 for further discussion)

There are several options for altering theinsulin dose with exercise. Experience is usuallythe best teacher to see what works. Doingmore frequent blood sugars to determine theeffects of the exercise and the changes ininsulin dosage is MOST helpful! Manyathletes find pumps are better than injectionswhen exercising. It is generally not as necessaryto eat and then perform on a full stomach.

4 If the exercise is mild to moderate (walking,golf, dancing, etc.), reducing the basaldosages by half (50 percent reduction)during the exercise may be sufficient. Somepeople start the reduction 30 to 60 minutesbefore the exercise and continue it for 30minutes or longer after the exercise is over.Every person is different and will need tofind what works best. Use of thetemporary basal can be very helpful.

Table 6Possible Pump ProblemsProblem Pump Alarm

Empty insulin reservoir (syringe) Yes

Low pump reservoir Yes

Clogged infusion set Yes

Partially blocked infusion set No

Leaky infusion set No

Weak or dead battery Yes

Low battery Yes

Pump malfunction Yes

Cannula has come out No

Spoiled Insulin No


4 If it is intense exercise (jogging, football,basketball, etc.), most people just disconnectfrom the pump (some disconnect 30 minutesbefore the start of the exercise).

There are then several options for insulinadjustments:

Estimate the amount of insulin to be missedwhile disconnected from the pump and takepart of the dose before the exercise(particularly if the blood sugar is high) andthe rest of the dose after the exercise. Youmay also consider using a temporary basalrate after an exercise of long duration and/orhigh intensity to lower the incidence ofdelayed hypoglycemia. This is particularlyhelpful during the night for some people.

l do a blood sugar test and bolus after theexercise (particularly if the adrenalineput out with the exercise raises theblood sugar)

l use a bolus of the entire amount missedwhile disconnected

l use 1/2 of the amount missed AFTERthe exercise

l Correction boluses given after exerciseare also frequently reduced by half. Thishelps to prevent delayed hypoglycemia(Chapter 13).

In general, if the pump is to bedisconnected for two hours or more, morefrequent blood sugars must be done(preferably each hour). If the blood sugar isrising, it is easy to reconnect, take a smallbolus and again disconnect.

4 If it is to be an all day exercise (e.g., a longhike or all day skiing), it may work best toreduce the basal and the bolus rates(perhaps by half) or possibly to not give anybolus doses. People must determine whatworks best for them.

4 With exercise, it is important to rememberto stay hydrated and to take extra snacks (seeChapter 13). Drinking water or Gatorade(or other sports drinks) works for somepeople. The carbohydrates from the sports

drinks will provide extra calories and energy.Often a bolus is not given (or reduced) tocover the carbohydrate intake. Snacks suchas granola bars provide extra carbohydratesand calories. Make sure that coaches orothers around at the time know that youhave diabetes and wear an insulin pump.

SMART PUMPSThe so-called smart pumps (as discussed

above) are those in which the insulin-to-carbratios for different times of the day as well ascorrection factors can be pre-entered. Thenwhen the carbs to be eaten and a glucose levelare entered, a recommended dose of insulin willbe suggested. The person can always overridethe recommendation. Getting into the habit ofentering all carbs, no matter how few, may helpestablish the bolus-for-food habit. The smartpumps also subtract the amount of insulin stillworking from the last bolus taken. Thisrequires entry of an estimate (usually three tofour hours) of how long the rapid-acting insulinworks in each person. Other features mayinclude a reminder to re-check a blood sugarlevel when the last value was low and alarms toremind the person to bolus if a bolus has notbeen given within a given time range (e.g., 11 a.m. to 1 p.m.). The latter feature has beenshown to be important in helping youthremember to give meal boluses.

SCHOOLIf the person using the pump is in school,

the school nurse should have some knowledgeof the pump. You may wish to copy the pumptable in Chapter 23 on Schools (or this entirechapter) for the school nurse. (You have ourpermission to make copies as desired.)

SUMMARY Insulin pumps have advantages and

disadvantages. It is up to each person andfamily, working with their healthcare team, todecide if a pump would be good for anindividual.


DEFINITIONSBasal dose: A pre-set hourly rate of insulin (for24 hours) as programmed into an insulin pump.

Bolus dose: An amount of insulin taken priorto a meal or when the blood sugar is high asentered at any time of the day by the personwearing the insulin pump.

Carbohydrate (carb) ratio (see Chapter 12):The number of units of insulin to be taken for acertain number of grams of carbohydrate eaten(e.g., one unit for 15g of carbohydrate).

Closed-loop pump: An insulin pump (notcurrently available) which would increaseinsulin given for high blood sugars or decreaseinsulin given for low blood sugars.

Correction bolus dose: A bolus of insulinused to correct a high blood sugar down to thedesired level.

Insulin pump: A microcomputer with asyringe of insulin within the pager-sized devicethat can infuse a basal insulin dose at a pre-sethourly rate. Bolus insulin dosages can also beentered and given at any time by the personwearing the pump.

Smart pump: This is the term given to a pumpthat will recommend units of insulin to givewhen the number of grams of carbs to be eatenis entered. It also recommends a correctioninsulin dose when the blood sugar level isentered or transmitted to the pump from theglucose meter. (The I/C ratios and correctionfactors must have been pre-entered into thepump by the user.)

ADDITIONAL READING1. Pumping Insulin (Everything In A Book For

Successful Use Of An Insulin Pump),Second Edition, by John Walsh, PA, CDEand Ruth Roberts, MS, Torrey Pines Press,1030 West Upas Street, San Diego, CA92103-3821

2. Teens Pumping It Up! Insulin PumpTherapy (Guide for Adolescents), byElizabeth Boland, MSN, APRN, PNP,CDE, Medtronic MiniMed, 18000Devonshire, Northridge, CA 91325, 1-800-933-3322

3. The Insulin Pump Therapy Book, Insightsfrom the Experts, edited by LindaFredrickson, MA, RN, CDE and Jay S.Skyler, MD, Medtronic MiniMed, 18000Devonshire, Northridge, CA 91325, 1-800-933-3322

4. H-TRONplus Advanced Insulin PumpProgramming and Practices, by DisetronicMedical System, Inc., 5201 East RiverRoad, Ste. 312, Minneapolis, MN 55421-1014, 1-800-280-7801

5. Pumper in the School!, edited by LindaFredrickson, MA, RN, CDE and Marilyn R.Graff, RN, BSN, CDE, MedtronicMiniMed, 18000 Devonshire, Northridge,CA 91325, 1-800-933-3322 orwww.minimed.com

6. Putting your Diabetes on the Pump,Francine Kaufman, MD et al. ADA, 2001.


QUESTIONS AND ANSWERSFROM NEWSNOTES

At what age should children withdiabetes be considered for insulinpump therapy?

This question is often asked. There isno magic age, although in general,teenagers tend to do better than pre-

teens. Other factors which are also important:

a. the person must be faithful in doing at leastfour blood sugars daily

b. the desire of the patient, and not just theparents, to use a pump

c. the patients maturity and ability to problemsolve

d. the patients ability to faithfully give thebolus dosages

e. the ability to use carbohydrate counting

f. family support

Some considerations:

4 Pumps are expensive at about $6,000(U.S.), and it is important to make sure theinsurance company will support thisexpense. The Diabetes Control andComplications Trial (DCCT) showed thatthe reduction in cost of caring for diabetescomplications in later years more thanmakes up for this cost. However, not allinsurance companies are willing to invest inprevention.

4 Starting insulin pump therapy is time-consuming. We require an initial 3-7 dayperiod of wearing the pump using saline(salt water). Then, if the person is stillmotivated, another half day is spent in theclinic to begin insulin treatment. We doNOT hospitalize people. Daily phoningand faxing of 6-8 blood sugars per dayfollows in the first week.

4 Some people have said that starting thepump can be like getting diabetes all overagain. Instead of taking shots in private, a

pager-sized device is now constantly worn.This is removed during intensive exercise.People may ask questions such as, What isthat on your belt?

4 An additional drawback of pumps is that ifthe plastic catheter accidentally pulls outand insulin is not being infused, high sugarsand ketones may develop in 3-6 hours. Thisis because only Humalog/NovoLog insulinis used in the pump, and it is a rapid-actinginsulin.

The rewards are also plentiful:

4 the HbA1c often declines

4 the likelihood of severe low blood sugars isnow less than for people receiving NPHinsulin

4 blood sugars are smoothed out with moreconsistent absorption of the insulin

4 people may have more energy or feel better

4 people may have more flexibility to choosethe time they eat meals

4 people may have more flexibility in choosingthe amount they eat

4 people may be able to vary the time theywake up in the morning

4 adjusting for exercise and activities can beeasier

Although pumps are not for everyone, if itis something you want to know more about, askyour healthcare providers at the time of yourclinic visit.

My son is going on a trip withoutother family members. He uses aninsulin pump. Could you remind

us of supplies he should be taking along?

In case of pump malfunction, wegenerally recommend he take extrasyringes and bottles of the

intermediate-acting/long-acting insulin he wason prior to starting the pump. You should alsolook back in your records to send the dosages as

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well. It is also important to have him pack hisdiabetes supplies in his carry-on luggage.

A summary of important items to include are:

1. clinic phone number

2. a supply of rapid-acting insulin

3. intermediate-acting/long-acting insulin

4. insulin syringes

5. extra pump batteries

6. glucose meter/strips/lancets

7. extra meter battery

8. extra infusion sets and inserter (if used)

9. extra pump syringe (reservoir)

10. alcohol pads

11. dressing, tape

12. glucose tablets/instant glucose

13. urine or blood ketone testing strips

14. glucagon emergency kit

Our teenage daughter is on aninsulin pump and seems to forget totake some of her insulin mealtime

bolus dosages. Do you have any suggestions?

Missing bolus dosages with food isunfortunately fairly common. It isprobably the number one cause of

elevated HbA1c levels (> 8 percent) for peoplewho receive insulin pump therapy.

When teens show signs of slipping, theparents must again get more involved. Theymay need to actually observe the breakfast anddinner boluses. Perhaps a friend or teacher canbe found to make sure the noon bolus is taken.

Some pumps have alarms to help remindyouth to bolus. The FreeStyle Flash meter alsohas four possible alarm settings.

One of our families found a Timex watchcalled the Iron Man Triathlon. It has fiveseparate alarms and can store 10 messages. Itcan be set as a reminder for bolus dosages.

I know pump supplies can beordered through the pumpcompanies. Are there other goodsources?

Yes, some families order throughGEMCO medical at 1-800-733-7976.Other families use IV-Solutions at 1-800-657-7122.

I am considering an insulin pump.I dont look forward to beingconstantly connected to the pump

and wonder if you have any thoughts?

A person does not have to beconstantly connected to a pump.People regularly disconnect for short

periods to participate in athletics, to shower orfor other reasons. Now that we have the basalinsulin, Lantus, it is quite easy to come off thepump for 24 hours or more. The units ofLantus are the same as the total basal units per24 hours used in the pump. One then takesinjections of Humalog/NovoLog/Apidrainsulin prior to any food intake just as bolusinsulin dosages are given with the pump.

People most commonly take pumpvacations when they are going to a beach. Ihave even had people come off the pump forthree months for a sports season and then goback on. They must remember that Lantuslasts 24 hours so they cannot restart the pumpuntil 24 hours after the last Lantus shot. If youhave further questions about this, ask yourdoctor or nurse.

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Pink Panther - Diabetes Management - Chapter 26