UNDERSTANDING THE BASIC

FEATURES AND MANAGEMENT IN THE

SCHOOL SETTING

CHRISTINE HERTLER RN BSN CDE

& MARY MCCARTHY RN CDE

The insulin pump

◦ Replaces injections

◦ Delivers insulin through a soft cannula under the skin

◦ Infuses rapid acting insulin in precise

programmable doses to meet

individual patient needs

The insulin pump closely mimics normal pancreatic insulin

delivery

6

Insulin

Cannula

Subcutaneous

Tissue

Skin

The insulin pump delivers basal and bolus insulin

precisely and can be easily customized as needed to

meet individual requirements.

Schematic representation only

Programmable Insulin Delivery with Medtronic MiniMed Pump Therapy

0

1.0

2.0

3.0

4.0

5.0

6.0

12am 4am 8am 12pm 4pm 8pm 12am

Bolus insulin delivery

Basal insulin delivery

Basal programmed

to help prevent

dawn phenomenon

Dual Wave™

Bolus for brunch

Temporary basal during walking

to help prevent hypoglycemia

Dinner bolus

Basal reduced

to help prevent nocturnal

hypoglycemia

Un

its

of

ins

ulin

It works more like a healthy pancreas

It has more predictable insulin absorption

It offers more flexible basal rates

It offers more accurate bolus dosing

Bode B, Sabbah H, Gross T, Fredrickson L, Davidson P. Diabetes management in the new

millennium using insulin pump therapy.

Diabetes Metabolism Research and Reviews. 2002; 18 (Suppl. 1): S14-S20.

Basal

Bolus

Insulin carb ratio -ICR

Insulin sensitivity or correction factor-ISF

Target

Active insulin or insulin on board -IOB

Basal Rate – (background insulin) -provides insulin continuously

Pre-programmed

Continuous flow of fast-acting insulin

Matches variable metabolic needs

May be overridden by temporary basal rate

Bolus - provides insulin for: ◦ Food Intake

◦ High blood sugars

Bolus is not automatic.

User determines bolus amount based on:

- Carbohydrate content of meal or snack

- Current blood sugar reading

Active insulin is the amount of insulin (remaining from previous boluses) that is still working to lower glucose

The pump tracks active insulin even if not using the Bolus Wizard feature

Tracking active insulin helps avoid:

◦ Giving too much insulin and over-correcting highs

◦ Lows that occur from over-correcting highs

Change infusion site every 2-3 days

Rotate site with every set change

◦ Recommended sites:

Abdomen- 2 inches from umbilicus

Buttocks- away from midline

Perform hand hygiene and use clean technique when inserting/removing catheter

Clean skin with alcohol or IV prep wipe

Allow to dry thoroughly before insertion

Remove set at first sign of discomfort

Place new set away from original site

At the first sign of infection advise family to contact primary care provider ◦ Signs of infection include:

Redness

Hardness

Tenderness

Oozing from cannula

Area warm to touch

Monitor site for any leakage, this may indicate displacement of cannula

Monitor site for lipohypertrophy and lipodystrophy- benign lesions which can affect absorption of insulin

If these occur stop using existing site for 4 weeks to allow healing

REVEL • Basal 0.025

increment • Bolus 0.025

increment 530G with Enlite Sensor • First phase artificial

pancreas • Integrated sensor

with pump • Low glucose

suspend • Linking meter

• Only tubeless pump

• PDM is linking meter and pump manager

• Insulin and pump in POD

• Bolus must be given with PDM

• Holds 200 units

• Basal .05 units

• Dose from ping linking meter/remote

• Low dosing basal .025

• Waterproof

• Holds 200 units

First touch screen

• Small

• Waterproof • Rechargeable-

green

Holds 300 units No linking meter

Hyperglycemia

Hypoglycemia

What to do for Exercise

What to do in an Emergency

Forgot to bolus? (Press Esc for last bolus)

Miscounted carbs? Illness or infection? Blocked insulin flow (No Delivery) Kinked Cannula at the infusion site?

When blood sugar is over 300 mg/dl for long periods of time, the body burns other energy sources to provide food for the body’s cells

Cells begin to break down to provide this energy

This cell breakdown can cause ketones to be released into the bloodstream

Risk of Ketoacidosis

increases on pump because no

long acting insulin is in the body • Monitor 4-6 times daily • Never ignore an unexplained

high glucose

Early-loss of appetite, nausea

Later-vomiting, abdominal pain

Late-difficulty breathing, confusion

Is my infusion site red or irritated

Is my site wet or does it smell like insulin

Are there bubbles in the tubing

Is there blood in the tubing

Are there any leaks or breaks

Is connection loose, easily moved Is reservoir loaded correctly?

Is reservoir empty?

Are there excessive bubbles in reservoir?

Has insulin vial expired?

Has insulin been exposed to extreme temp?

Was last meal bolus missed (check bolus history)

Are basal rates set incorrectly?

Is time (am or pm) set correctly?

Is insulin pump not working????

WHEN BLOOD GLUCOSE IS 300 OR HIGHER CHECK FOR KETONES AND FOLLOW THESE

GUIDELINES

Give correction dose by injection

Change infusion set, reservoir

and insulin

Monitor blood sugar every hour

to make sure until BG is

lowering

Check ketones with every void

until negative

Force fluids

Never exercise when ketones are

positive

Positive Ketones Negative Ketones

Give correction dose via

insulin pump

Recheck blood sugar in 1 hour

If blood sugar has not

decreased:

-give ½ dose by syringe

-change infusion set,

reservoir and insulin

Continue to check for ketones

Check blood glucose 2 hrs

from correction dose

If moderate to large ketones present, there is an increased resistance to insulin---CALL HOTLINE

•The insulin given for correction may need to be increased by 50%

–Example:

•If 151-200mg/dl = 1 unit

•1 divided by 2 = 0.5

•1 unit + 0.5 units = 1.5 units (correction increased by 50%)

•This increase in correction can only be done twice, unless recommended by the hotline

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Muscles will use glucose during exercise and activity – this can affect BG levels for several hours

Disconnecting from the pump

Using a temporary basal rate decrease

Consuming extra carbs before exercise per physician order

Discuss which plan to use with parents (504) and follow

physician school orders

Manage hypoglycemia the same way as you would if child were on injections

◦ 15 and 15 rule=15gm recheck in 15 min

◦ follow physician school order and parents’ guidelines

◦No need to disconnect pump

Fast acting carbohydrates for low blood sugar

Insulin and syringes

Extra infusion set and reservoir (plus inserter if necessary)

Extra batteries

Alcohol or skin prep

Phone # of student’s diabetes clinician

Blood glucose meter

Keto-stix

Glucagon kit

42

BENEFITS OF CGM

• Aids in the detection of highs and lows allowing for adjustments

for minimizing excursions

• Identifies patterns that otherwise would not be detected by

fingerstick alone

• Provides info about the effects of food intake, EXERCISE and

timing of insulin

• Provides glucose direction and rate of change

• Accuracy within 10-15 % at this time

• Complements but does not replace monitoring

Medtronic Enlite 530G-pump integrated

Dexcom

G4 -pump -integrated with Animas Vibe an T-Slim

G5 -stand alone sensor

530G with Enlite Sensor • First phase

artificial pancreas

• Integrated sensor with pump

• Low glucose suspend

• Linking meter

• BLUE TOOTH COMMUNICATION FROM DEXCOM G4 SENSOR TO PUMP

• NO METER

REMOTE • SEPARATE

DEXCOM RECEIVER MAY BE USED TO ALLOW FOR COMMUNICATION TO CELL PHONE

• STUDENT WILL ALSO HAVE TO CARRY CELL PHONE FOR CLOUD

CGM enabled Large capacity Rechargeable Watertight Touch Screen

Enlite® glucose sensor

MiniLink® transmitter

MiniMed® 530G insulin pump

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DEXCOM SENSOR COMPONENTS

Recommended sites:

◦ Abdomen & Buttocks

◦ At least 2 inches away from insulin pump site

Change sensor site every 6-7 days

May encounter issues with tape adherence and skin sensitivity

Products that may help

◦ Skin Tac

◦ Bard Barrier Wipe

◦ Mastisol

◦ IV 3000

◦ Tegaderm

◦ Tincture of Benzoin

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LOW

ALERT

HIGH ALERT

TARGET GLUCOSE

RANGE

CURRENT GLUCOSE READING

WHEN IN ACTIVE SESSION

TREND GRAPH

VIEWS BY TIME

My CGM IS TALKING TO ME!

WHY ARE YOU USING YOUR CELL PHONE IN SCHOOL?

When glucose is rising, then the difference between the Sensor Glucose and Blood Glucose readings tends to be greater

Blood Glucose tends to be ahead of the Sensor Glucose Both SG and BG readings will be similar

Focus on the direction and speed of your sensor glucose Arrows mean the sensor glucose has been changing rapidly

RESPONDING TO ALERTS

Dexcom receiver and/or cell phone must be within 20 foot range for communication

Medtronic enlite sensor, will communicate directly to pump and is already in range-if using a uploader, it must be within 6 foot range of body and cell phone

The sensor is worn continuously-the cell receiver, pump or cell phone has audible alerts warning to indicate glucose level out of range

When an alarm or alert sound is sounding, student, teacher or other designated person will need to clear alarm and check blood glucose by fingerstick

ALL ALERTS MUST BE CONFIRMED WITH A FINGERSTICK BEFORE TREATING ANY GLUCOSE READINGS

The nurse (or other designated person) should the low glucose as per protocol, notify parent as usual, and document both the fingerstick and sensor glucose results, along with the necessary treatment given

Please note that looking at TREND ARROW DIRECTION is helpful If the glucose sensor becomes detached from the body, store the device

safely without discarding any components-return this to the parent

THIS IS NOT AN EMERGENCY AND DOES NOT REQUIRE ANY SPECIAL INTERVENTION OR EXCUSING THE CHILD FROM SCHOOL ACTIVITY

Physician school orders still take precedence

Monitoring at regular intervals

Confirming alerts with fingersticks before treatment

504 plans will need to be updated which address parental concerns, use of cell phones, and accountability of student to report to health office

QUESTIONS???