Transcript Thinking Outside - Johnson & Johnson

Advanced Pumping
Objectives:
• Identify situations to utilize temporary basal
rate in pump therapy patients.
• Identify examples of when to use
combination and extended bolus in pump
therapy patients.
• Verbalize understanding of the insulin on
board feature available in current insulin
infusion pumps.
• Identify sick day and DKA clinical
management guidelines for treatment
Activity
• In table teams take 2 minutes to discuss
what a temporary basal is?
• Come up with 3-5 reasons you might use
one and write them on the flip chart.
Temporary Basal Rate
• Allows patient to increase or decrease
basal rate for a specific period of time
based on percent change or units/hr.
– Example:
• 50% reduction for 2 hours
• 20% increase for 4 hours
Clinical Indications for Use of a
Temporary Basal Rate
• Illness or infection
• Change in normal
routine
– Travel
– Work
• Medications
– Steriods
• Stress
– Holidays
– Exams
• Exercise
Temporary Basal Rate and Exercise
• With multiple daily injections (MDI), the
patient must snack or adjust the rapid or
long-acting insulin
• With pump therapy, a temporary basal
change allows the patient to immediately
adjust the amount of insulin being infused
Education for Temporary Basal Use
• Check BG frequently to evaluate
temporary basal effectiveness
• Start conservatively with a decrease or
increase of 10-20%
• Ability to stop temporary basal at anytime
Evaluating Effectiveness of
Temporary Basal Rate
– Absence of hypoglycemia/hyperglycemia
during exercise
– Absence of nocturnal or post-exercise
hypoglycemia
– Decrease in extra snacking to prevent
hypoglycemia
– May need to increase or decrease percentage
change
Activity
• In table teams take 2 minutes to discuss
what is an extended bolus? What is a
Combo bolus?
• Come up with 3-5 reasons you might use
would use them.
Extended Bolus
• Bolus extended over a designated period
of time
• Elements of extended bolus
– Dosage
– Duration
Example
• 4 units delivered over 2 hours
• 6.5 units delivered over 4 hours
Combo Bolus
• A portion of bolus is delivered immediately
(normal) and a portion is extended over a
designated period of time (combo)
• Example: 25/75 split using 4 unit bolus
would deliver…
– Normal
(1 unit)
• To cover portion of CHO or high BG
– Extended (3 units)
• To cover high fat bolus or grazing at meals
Clinical Indications for Extended or
Combo Bolus
• High post-prandial BG’s despite accurate
CHO counting
• Hypoglycemia immediately following meal
• Grazing, extended eating
– Buffets
– Holiday Meals
– Parties
– Movies
Clinical Indications for Extended or
Combo Bolus
• Gastroparesis
• Slow eaters, such as young children
• Large bolus dosage
– May prevent depot of insulin at injection site
• Nutrient composition of meal
– High fat
– Low glycemic foods
– High protein
Evaluating the Effectiveness of an
Extended or Combo Bolus
• Check BG at 2, 4, 6 & 8 hours after meal
• If BG remains in target bolus was
successful
• If BG goes low or rises more than 40-80
mg/dL combo bolus needs to adjusted,
consider:
– Percent split
– Dose
– Duration
Foods Effect on Blood Sugar: Protein
• Rate of digestion and conversion to
glucose depends on state of insulinization
and glycemic control
• BG effect difficult to predict
– Up to 50-60% can be converted to glucose
Foods Effect on Blood Sugar: Fat
• Effects on BG
– Delayed stomach emptying
– Decreased insulin sensitivity
– Increased insulin resistance
– May last for hours after eating
• Minimal fat actually converted to glucose
(<10%)
• Individual’s response needs to evaluated
Insulin on Board (IOB)
• After bolus is delivered, IOB tracks bolus
insulin still active
• Customizable IOB from 1.5 hrs - 6.5 hrs
• May decrease risk of stacking insulin
– Potential for less hypoglycemia
What is the effect of illness on BG?
• Typically BG is elevated during illness
– Liver Glucose release increases
– Cells less sensitive to insulin
– May have low BG instead
• Vomiting
• Diarrhea
Activity
• In table teams, take 3 minutes to discuss
what causes DKA?
• What are you currently doing in your
practice – to prevent and or treat DKA?
• Write current practice guidelines on the flip
chart
Causes of Diabetic Ketoacidosis - DKA
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Inadequate or missed insulin dose
Illness
Infections
Stress
Infusion set or site issue
Dehydration
Insulin Pumpers and DKA
• Insulin Pumpers are at a higher risk for
DKA
• Only use rapid acting insulin
• BG can start to rise within 60-90 minutes
of interrupted insulin delivery
• Lack of immediate or long-acting insulin
Problem Solving
• Check for Ketones – early detection of
interrupted insulin delivery
• Check tubing for bubbles
• Assess infusion site for placement, kinks,
disconnection
• Cartridge – insulin available, cracks
Prevention of DKA
• Check your BG at least 4 times a day
• For "unexplained” BG > 250mg/dl or
higher -- Check ketones
• Take correction bolus by syringe
• Change your insulin set and site
– Disconnect from the body before priming
• Drink plenty of fluids
Activity
• In table teams, take 3 minutes to discuss
your sick day management plans
• List plan on flip chart
Sick Day Plan To Include…
• When and who to call
• Frequency of BG testing
• Frequency of Ketone testing
– Blood vs Urine testing
• Use of a temp basal, duration of setting
• Recommendations for vomiting or diarrhea
– What to eat, what if you have given insulin
and then vomit.
– Possible use of Glucagon for vomiting
induced hypoglycemia