Insulin Pump Calculations Sept 2019 Handouts 3pp
Diabetes TechnologiesInsulin Pump CalculationsBeverly Thomassian, RN, MPH, BC-ADM, CDEPresident, Diabetes Education Services
Diabetes Technologies – Insulin Pumps 1. Describe critical teaching content beforestarting insulin pump therapy2. Discuss strategies to determine insulinpump basal rates.3. Discuss how to determine and evaluatebolus rates including coverage for carbs andhyperglycemia.4. State important safety measures toprevent hyperglycemic crises.5. List inpatient considerations for insulinpump therapy and CGMs6. Describe 3 essential steps for emergencypreparedness.
Conflict of Interest and Resources Coach Bev has no conflict of interestTechnology field is rapidly changingPhotos in slide set are from Pixabay – not actual clientsResources AADE Practice Paper 2018- Continuous Subcutaneous Insulin Infusion(CSII) Without and With Sensor IntegrationAADE Practice Paper 2018- Diabetes Educator Role in ContinuousGlucose MonitoringCompany web sites – virtual demoAADE – DANA Diabetes Advanced Network Accesswww.diabeteseducator.org Need to be AADE Member to accessDiabetes Forecast Consumer Guide 2019Pumping Insulin by John Walsh, PA, CDE – Diabetes MallGary Scheiner, MS, CDE – Integrated Diabetes Services
Pump Candidates: Lifestyle Indications andAttributesErratic schedule Varied work shifts Frequent travel Desire for flexibility Tired of MDI Athletes Temporary basal adjustDisconnect optionsWaterproof options
LifeStyle Indications for Candidate or Parents ofPump Wearer Parents and caretakers musthave a thoroughunderstanding and willingnessand time to understand thepump and work with team toproblem solveWillingness to work withhealthcare provider duringpre-pump trainingAdequate insurance benefitsor personal resources
LifeStyle Indications for Candidate or Parents ofPump Wearer Physical ability View pumpFill and replace insulin cartridgeInsert an infusion setWear the pumpPerform technical functionsEmotional stability andadequate emotional supportfrom family or others
Pre Pump Knowledge / Education Establishment of GoalsCompetence in Carb counting Insulin Carb Ratios (ICR) & Correctionor sensitivity factor (CF) Ability to manage hyper andhypoglycemiaSelf-adjust insulin Carbs Correction Physical activity Alcohol intake
Pre Pump Knowledge / Education Ability to fill and insertcartridge/reservoir and insert andchange infusion setsAbility to detect infusion set and siteissuesManage sick days, exercise and travelTrouble shoot and ability to solvepump issuesUnderstand BG DataHypo prevention and treatmentBasic of basal bolus therapy and howto switch back to injections if needed
Caregiver education about pumps Key Topics Hypo detection /treatmentHyperglycemia troubleshootingBasic bolus procedureCartridge set changeprocessUnderstand what alarmsmeanHistory recall
Poll Question 1Teenagers benefit from insulinpump therapy for the followingreason. A. Can increase insulin rate to coverfor alcohol intake. B. Decreased risk of glucoseemergencies C. Greater dependence on parents D. Match insulin to hormone swings
Toddlers to Teens Benefit Delayed blousing for fussy eatersDosing precision 10ths 20ths and40ths of a unitReduced hypo riskLockout featuresTeens Basal patterns for hormonalswings Historical data records/downloading / app sharing Easy snack coverage Greater independence Technical coolness
Written Plan for Pump Use Blood glucose checks or CGMChecksRecord keeping of BG, Carbs,insulin, activity and other issuesSite-change guidelinesRestart injections if neededWhen to check ketones andaction to takeHypoglycemia andHyperglycemia treatmentguidelines
CGM Time in Range Recommendations For most with type 1 or type 2 diabetes 70% of readings within BG range of 70-180mg/dL 4% of readings 70 mg/dL 1% of readings 54 mg/dL 25% of readings 180 mg/dL 5% of readings 250 mg/dL For under 25 years, with A1c goal is 7.5%, time-in-rangetarget is set to about 60%.Clinical Targets for Continuous Glucose Monitoring Data Interpretation: Recommendations Fromthe International Consensus on Time in RangeTadej Battelino et al. Diabetes Care Aug 2019, 42 (8) 1593-1603; DOI: 10.2337/dci19-0028
Time in Range Older Adults For older adults or those at highrisk for hypoglycemia (ie,hypoglycemic unawareness,cognitive impairment, orcomorbidities): 50% of BG within 70-180 mg/dL 1% of readings 70 mg/dL 10% of readings 250 mg/dLClinical Targets for Continuous Glucose Monitoring Data Interpretation: Recommendations Fromthe International Consensus on Time in RangeTadej Battelino et al. Diabetes Care Aug 2019, 42 (8) 1593-1603; DOI: 10.2337/dci19-0028
Time in Range Pregnancy For those with type 1 diabetes andpregnant: 70% of BG readings within 63-140 mg/dL 4% of readings 63 mg/dL 1% of readings 54 mg/dL 25% of readings 140 mg/dLClinical Targets for Continuous Glucose Monitoring Data Interpretation: Recommendations Fromthe International Consensus on Time in RangeTadej Battelino et al. Diabetes Care Aug 2019, 42 (8) 1593-1603; DOI: 10.2337/dci19-0028
Let’s practice calculating basal rates
TDD Total Daily DoseTDI Total Daily Insulin
TDD insulin practice – TDD 30 units / 70kg Method 1 (TDD) Method 2 (wt) TDD x 0.7530 units x 0.75 22.5Pt wt kg x 0.5070kg x 0.50 35Final daily dose A1c 6.3% - Method 1A1c 9.2% - Method 2A1c 7.5% - Take avg 1 & 2
Example – LS weighs 80 kg, TDD 50 units,A1c 8.2%Method 1 – Based on TDD 50 x.75 37.5 units total daily dose37.5 x 0.5 18.75 units for basal18.75 divided by 24 hrs 0.78 units/hr(Basal rate)Method 2 – Based on body wt 80kg x 0.5 40 units40 x 0.5 20 units for basal20 divided by 24 hours 0.83 units/hr(Basal rate)Which method would you use?
Example – JR weighs 70 kg, TDD 30 units,A1c 6.3%Method 1 – Based on TDD 30 x.75 22.5 units total daily dose22.5 x 0.5 11.25 units for basal11.25 divided by 24 hrs 0.47 units/hr (Basal rate)Method 2 – Based on body wt 70kg x 0.5 35 units35 x 0.5 17.5 units for basal17.5 divided by 24 hours 0.73 units/hr (Basal rate)Which method would you use?
Example – KL weighs 40 kg, TDD 20 units,A1c 6.2%Method 1 – Based on TDD 20 x.75 units total daily dose15 x 0.5 units for basal7.5 divided by 24 hrs units/hr(basal rate)Method 2 – Based on body wt 40kg x 0.5 units20 x 0.5 units for basal10 divided by 24 hours units/hr (basal rate)Which method would you use?
Basal insulinDrip of rapid insulin very fewminutes If basal rate is set correctly, stableBG between meals and hs Can skip delay mealsDelivered auto on 24 hour cycle Temporary adjustments mayinclude: lower basal insulin during exerciseincrease during sick days
Basal insulin feedback Keep glucose steady On average, 5 different basal segmentsneededBasal insulin rate not correct Glucose rises or falls even when not eatingFasting glucose is elevated or lowCorrection bolus does not get glucose totargetTo prevent hypoglycemia, not covering forsnacksIf person is eating to cover for in-betweenmeal hypoglycemia
Basal Insulin Needs Dawn phenomena Higher needs from 3-7amfor adultsKids from Midnight to 7amBasal rate can be adjustedto match sleep and workscheduleTraveling – changeclock in pump to matchnew time
Typical Basal NeedsGary Scheiner, MS, CDE
Basal Insulin Dosing – Beyond Basics Active, healthy 35-45% of total daily insulinLess active, lower carb intake 45-55% of total daily insulinPercentage may increase duringpuberty Tends to decrease with advanced age Sleep and growth patterns have majorinfluence
Adjusting basal rates – think aheadTakes time for basalrate to affect glucose For children: changein basal rate 1 hourprior to rising orfalling glucose For adults: change inbasal rate 2 hourprior to rising orfalling glucose Repeat basal testafteradjustmentCurrent basal level (units /hr)0.0 – 0.45ModestRise/Fall(30-60 mg/dl)Large Rise/Fall( 60 mg/dl)0.5 – 1.2 1.2.050.10.20.10.150.3
Bolus Rate Calculations are nextI:C Sensitivity Timing Considerations
Bolus Rates - Same for each meal to start CHO Ratio Correction/sensitivity 1700 divided by TDDActive insulin/insulin On Board Start with 1:15 or450 divided by TDD I:C Ratio3-6 hoursTime in Range target: 70-180 mg/dl
Insulin to Carb Ratio I :C 450 / Total Daily Dose 450 Rule I:C 450/TDD450 divided by total dailyinsulin dose.Equals Gms of carbcovered by 1unit insulin.Example:Pt takes 45 units daily.450 / 45 101 unit for 10 grams carbYou try JR TDD is 90 units 1 unit for gms carbYou try ML TDD is 15 units 1 unit for gms carb
Example – JR injects 30 TDD, A1c 6.7%30 x.75 22.5 units total daily dose 22.5 x 0.5 11.25 units for basal 11.25 divided by 24 hrs 0.47 units/hr Basal rate is 0.5 units hr What is his I:C ratio? 450 / 22.5 20 I:C Ratio 20
Insulin /Carb Ratio - How does that work?TDD 40 units, A1c 8.2% Uses HumaloginsulinDinner Calculate Insulin to Carb RatioUse 450 rule450 / TDD450 / 40 11.25(round down to 11)1 unit Humalog for each 11 gmsof carbInsulin/Carb Ratio I:C 1:11 4 ounces steak1 dinner roll1 cup mashedpotatoesFew sprigs broccoliGlass of white wineHow much bolus for this meal?What if she ate 60 gms?BG is 220 – Target is 120
Covering Carbs with Insulin Dose based on: Grams of carb in mealInsulin carb ratio or fixed dose?Right dose? Brings glucose to prebolus glucose level within 3-4 hoursIf BG rises more than 60 - 80 points 2 hours post meal,needs adjustmentIf BG falls more than 30 points 2 hours post meal, mayneed adjustmentAdjust in small increments (10-20% ideal)
But wait what about correction insulin forcurrent glucose level? 1700/TDD - Target 120TDD 40 units Correction/sensitivityBG target is120. 1700 divided by TDDCurrent BG is 220. 1700 / 40 42.5 or 43Based on her Correction: I unit of insulincurrent BG, howlowers BG 43 points.much correctioninsulin does sheneed to get to220 – 120 100 over targettarget?100 / 43 2.3 units to correct for hyperglycemiaWhat if her BG is 320?320 – 120 over targetunits to correct for hyperglycemia
Correction Insulins ExampleCorrection Factor Fine-TuningMathematical ApproachThe lower the TDI more insulin sensitiveCorrectionScale / TDISensitivitymg/dl 30 unitsSensitivitymg/dl 40 unitsSensitivity mg/dl50 unitsAggressive(1500) 1500 / TDI503830Common(1700) 1700 / TDI574334Conservative(2000) 2000 / TDI675040
But wait, what about IOB?Insulin to Carb Ratio I:C450 / TDD450 / 40 111:CR 1:11Correction/sensitivity1700 divided by TDD1700 / 40 42.5Correction: I:43 points.
Active Insulin time - IOB How much “insulin on board” IOB toprevent stacking and hypoglycemiaTypical active insulin time is 3-5hours Average about 4 hoursAction time shorter in leaner,young, active individuals in hotclimatesAction time is longer, 6-8 hours, forthose with renal disease or usingregular insulinCareful monitoring or CGM to eval ifbolus rates set correctly
Pump Bolus Estimate Features Based on glucose and carb data entered by userBolus Estimate DetailsTotalFood intakeBGFood DoseCorrection DoseInsulin-On-Board8.1 U75 gms2206.8 U2.3 U1.0 U(Based on BG and Carbsentered by user.)ICR1:11 gmsCorrection 1unit for 43Target BG 120Active insulin on board (IOB)subtracted from the correction75 gms carb/11 6.8 unitsCorrection 220-120 100/43 2.3 unitsIOB 1 unit6.8 2.3 9.1 – 1 units 8.1 unitsBolus delivery of 8.1 units
What bolus would this person need? Plans to eat 75 gms Carb SnackBG is 68Bolus Estimate DetailsTotalFood intakeBGFood DoseCorrection DoseInsulin-On-BoardU75 gms68?.0 U?.0 U2.0 U(Based on BG and Carbsentered by user.)ICR1:15 gmsCorrection 1unit for 50Target BG100Active insulin on board (IOB)subtracted from the correction75 gms carb/15 ?unitsCorrection -100 /50 ?unitsIOB 2 unitTotal insulin ?units
Poll Question 2 For case study, how much bolus insulin? A. 3.6 units B. 2.4 units C. 4 units D. Determine activity first
Not using insulin/carb bolus ratios? Fixed dosing Take half of total dailydose, divide by number ofmeals to get fixed doseper mealCalculate insulin sensitivitycorrection factor 1700 by total daily insulinNo target BG – chooseacceptable target range40 units x 0.5 for basal and bolus20 units/24 for basal 0.83 hr20 units for bolus20 units/3 meals7, 6, 7 units per meal plus correctionCorrection 1700/40 units 1:43
Advanced Pump Features Prolonged bolus for Advanced Basal Features Gastroparesis, amylin, GLP-1Receptor AgonistsTemporary basal ratesSecondary, tertiary programsCustom alerts examplesA1c of 13% - Alarm at 70A1c of 8% - Alarm 70 – 300A1c of 7 % - Alarm 70-250 Data downloads
Prolonged bolus Standard bolus Delivered within a fewminutesPeaks in one hourLasts for 4 hoursProlonged bolus Delivered over a coupleof hoursPeak delayDuration extendedPurpose Match insulin toabsorption of foodWorks well with slowlydigested foodApplications Large portionsSlow consumptionGastroparesisUse of incretin mimetics
Prolonged bolus Square/extended None of the bolus isdelivered up frontCommon timing is 1-2hours after start of mealCan last for up to 8hours Dual/combo/combination bolus 30% delivered up front,the rest of bolus overthe next several hours.Lasts about 5 hours
Insulin coverage for protein?Most of time, proteinwon’t affect glucose If person on low carb diet,protein may startimpacting blood glucoselevels Bolus for 50% of protein gramsIf large protein portionconsider extended bolus
Problem solving Prevent missed boluses 1 missed meal bolus over a monthraises A1c 0.5%Get in habit of pre-bolusing – 15minutes before meal works bestUse reminder alerts on pumpsIf basal or bolus is more than 65% oftotal daily dose, usually indicatesneed to recalculate ratios
Disconnecting from Pump BG rises about 1 mg/dl aminute when disconnected Avoid extendeddisconnection since can leadto ketones and hyperglycemiaStrategies Short term disconnection 1 hour Bolus to replace missed basal insulinLong term 1 hour and bolusmissed basal insulin hourlyProtective caps usually notnecessaryWith pump therapy,there is nobackground insulin onboard
Safety guidelines Review signs and treatment ofhypoIf frequent lows, may want toset pump alarm at 90 Try not to suspend pump when low,unless no treatment availableDiabetes Ketoacidosis Those with negative c-peptide athigher riskInsulin pump interruption for 2-3hours can lead to DKAProvide education to prevent,detect and reverse
Poll Question 3 AL is on an insulin pump. Her BG at10am is 108, at 11am, 219 andnoon 298. She has not eatenanything since breakfast. What isbest action?A. Program insulin pump to deliver3 units bolus statB. Increase basal rate starting at8amC. Go to emergency roomD. Check for ketones
Prevent DKA and Hyperglycemia Eval sites for malabsorption, make sure to changesite and infusion sets every 2-3 daysProtect insulin from overheatingTubing or infusion set clogs – change siteCheck for leaks, smell for insulin, use angled setsMake sure to purge air bubbles before primingtubeInspect daily for dislodgementCorrect priming technique when changinginfusion setExtended pump suspension or disconnect?Limit suspension to one hour, always have backup syringes
Action in Case of Hyperglycemia for Pump Users Unexplainedhyperglycemia Ketonenegative KetonepositiveCheck forKetonesBolus with pumpInject insulinDrink H20Change outpump
Ketone Testing Options Urine ketostix or diastix More than 15 mg/dl positive ketonesBlood sampling Novamax or Precision Xtra blood meterMore than 0.5 mmol/l β – hydroxybutyrateindicates action and insulin neededhttps://www.novabio.us/nova-max-plus/
Keeping connected - Pump Users need tocontact clinical staff if:Severe or repeated hypo Ketosis Signs of infection Call pump company if technicaldifficulties See pumper in 1-2 weeks,download device, troubleshooting At 3-4 weeks review moreadvanced features
Diabetes Care 2018;41:1579–1589
Hospital Stay for Insulin Pump Users Staff to assess: How long using pump?Who adjusts pump settings?What type of insulin is used?How much insulin is in pump now?When is next site change? Who does it?Basal rates? I:C ratios? Correction?Have your supplies?When usually check BG or CGM?
Hospital Stay - Need orders Backup plan in case pump can’t beusedDon’t stop pump without administeringrapid insulin first (or IV insulin).Designate surrogate programmer(s)Specify frequency and carb count formeals/snacksKeep pump and programmer outsideroom during MRI, CT Scan, Xray.Don’t aim Echo/US transducer at pumpCGM - Remove infusion set and sensorfor MRI Hospital meter to determine BG levelsRefer to individualtech user manualfor more detailedinfo
Pumpers Responsibility in HospitalProvide own pump (and sensor)supplies Change pump reservoirs andinfusion sets Provide staff with SMBG andinsulin doses Notify staff of adjustments tostandard doses Respond to alarms
Backup Plan if pump isn’t workingImmediate basal insulininjection Mealtime rapid insulininjection Keep written log of I:C ratios,correction and meal boluses Keep log of off-pump activity Resume pump when basalinsulin wears off
Poll Question 4 TR wears an insulin pump andcontinuous glucose monitor. Inpreparation to pass through airportsecurity, which of the actions arerecommended?a.b.c.d.Carry source of fast actingcarbohydrateKeep continuous glucose monitor incarry-on bagPack insulin back-up pens in checkedin suitcaseDisconnect insulin pump and put ontemporary suspend mode
Travel Suggestions from Diabetes.org Review TSA's website for travelupdatesDownload My TSA Mobile AppWhenever possible, bringprescription labels for medicationand medical devices (while notrequired by TSA, making themavailable will make the securityprocess go more quickly)Consider printing out and bringingan optional TSA DisabilityNotification Card.
What about diabetes Tech andSecurity?Refer to training manualfor each manufacturer To be safe, ask for patdown if wearing pump,CGM or both
Travel Suggestions from Diabetes.org Pack medications in a separate clear,sealable bag. Bags that are placed inyour carry-on-luggage need to beremoved and separated from yourother belongings for screening.Keep a quick-acting source of glucoseto treat low blood glucose as well asan easy-to-carry snack such as anutrition barCarry or wear medical identificationand carry contact information foryour physician
Travel: What items allowed? Insulin and insulin loaded dispensing products(vials or box of individual vials, jet injectors,biojectors, epipens, infusers and preloadedsyringes)Unlimited number of unused syringes whenaccompanied by insulin or other injectablemedicationLancets, blood glucose meters, blood glucosemeter test strips, alcohol swabs, meter-testingsolutionsInsulin pump and insulin pump supplies(cleaning agents, batteries, plastic tubing,infusion kit, catheter and needle)—insulinpumps and supplies must be accompanied byinsulin
Travel: What items allowed? Glucagon emergency kit, Urineketone test stripsUnlimited number of used syringeswhen transported in Sharps disposalcontainer or other similar hardsurface containerSharps disposal containers or similarhard-surface disposal container forstoring used syringes and test stripsLiquids (to include water, juice orliquid nutrition) or gelsContinuous blood glucose monitorsAll diabetes related medication,equipment, and supplies
Poll Question 5 JL is on an insulin pump and CGMand asks the diabetes educator howto best prepare for emergencysituations. What is the most criticalstep to take in case of an emergencyevacuation?A. Have back up energy sourceB. Keep insulin on iceC. Know the CDCs info line numberD. Alert local emergency respondersof status
Medical Diabetes Identification Speaks when you cannot Necklace, bracelet orwatch band A wallet card isadditional identificationonly3-15
Prepare A Portable Emergency Kit
www.diabetesdisasterresponse.orgPlease check outthis DiabetesDisaster ResponseResource Page.Let’s help getpeople ready forthe worst.
Disaster Readiness American Red CrossShelters: Contact the AmericanRed Cross directly at 1-800-REDCROSS.Resource For Health CareProviders: Insulin Supply Hotline: During a disaster,call the emergency diabetes supplyhotline 314-INSULIN (314-467-8546) ifyou know of diabetes supply shortages inyour community (i.e. shelter, communitycenter). Hotline is for health careproviders only.
Disaster Readiness Have an Emergency Diabetes Kit Ready:People with Diabetes can download the DiabetesDisaster Response Coalition’s(DDRC) Diabetes Preparedness Plan.Stay Updated: Visit JDRF Disaster Relief Resources andDiabetes Disaster Response Coalitions Facebookpage with information on how to access medicalsupport, shelters, and open pharmacies during time ofdisaster.Know where to get help:Call 1-800-DIABETES (800-342-2383).American Diabetes Association Center is open, MON.FRI. 9 a.m. TO 7 p.m. ET.Representatives regularly updated with information onhow to access medical support, shelters, pharmacies
Thank YouPlease email us with anyquestions. bev@diabetesed.net www.diabetesed.net
Insulin to Carb Ratio I :C 450 / Total Daily Dose 450 Rule I:C 450/TDD 450 divided by total daily insulin dose. Equals Gms of carb covered by 1unit insulin. Example: Pt takes 45 units daily. 450 / 45 10 1 unit for 10 grams carb You try JR TDD is 90 units 1 unit for _ gms carb You try ML TDD is 15 units 1 unit for _ gms carb
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Insulin NPH and insulin regular (HumuLIN 70/30) Insulin NPH and insulin regular (NovoLIN 70/30) Concentrated insulin Insulin regular (HumuLIN R U-500) 11. Please select the statement(s) that best describe(s) the distribution of insulin used for subcutaneous admi
humalog mix 75/25 kwikpen humulin 70/30 humulin 70/30 kwikpen humulin n humulin n kwikpen humulin r humulin r u-500 (onentrated) humulin r u-500 kwikpen insulin aspart insulin aspart flexpen insulin aspart penfill insulin aspart protamine/insulin aspart insulin aspart protamine/insulin aspart flexpen insu
Risks of an insulin pump People using an insulin pump can be at higher risk for diabetic ketoacidosis because there is a small amount of insulin in the body at any given time. If the pump is not giving you insulin for any reason, blood sugars can start to rise within 90 minutes. This is usually caused by a dislodged cannula or a poor site.
Appendix D: Insulin Pump Order Form Appendix E: S.C. Insulin Pump Order Form Appendix F (a): Home Insulin Doses on Injections – Basal/Bolus Regimen Appendix F (b): Homes Insulin Doses on Injections - Sliding Scale/Pre-Mixed Appendix F (c): Home Insulin Does on Pump
Novo Nordisk, Bagsværd, Denmark) or insulin glargine (Lantus, 100 U/mL, subcutaneously, 3 mL SoloStar, insulin and insulin pen manufactured by Sanofi , Paris, France), both in combination with meal-time insulin aspart (NovoRapid/NovoLog, 100 U/mL, subcutaneously, 3 mL FlexPen, Novo Nordisk, Bagsvaerd, Denmark), by means
Starting to wear an insulin pump is an exciting time. It's important to begin with realistic expectations about what an insulin pump can and cannot do. A pump can improve blood glucose control, but you must continue to check glucose levels using a continuous glucose monitor (CGM) or glucose meter. You must still give insulin based on .
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