7/16/2014
Jackie Aday RN, BSN, CDE
Jeni Neighbors RN, BSN, CDE
Insulin Pump Therapy
Open looped system in which a small amount of insulin is continuously infused through a cannula or needle (basal rate)
Larger doses of insulin (boluses) are given prior to meals and to correct high blood glucose.
Boluses have to be programmed by the patient each time needed.
Basal and Bolus Insulin
 BASAL:
Small amount of insulin infused every few minutes
 BOLUS
Programmed before each meal and for high blood glucose.
Burst of insulin Insulin used in pumps: Humalog, Novolog, Apidra,
Humulin Regular u‐500
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7/16/2014
Infusion Sets
 Angled cannulas: Comfort, Inset 30,Silhouette, Tender
13mm and 17mm length  90 degree cannulas: Cleos, Insets, Mios Quicksets, Mios
6 or 9mm length
 Metal needles(Contact Detach and Sure T)
 Pods
Most infusion needle sets have inserters
Inserters recommended or insertion needs to be done
quickly.
Infusion Needle Sites
 Abdomen‐ Stay at least 2 inches away from the belly button. Avoid scars
 Hips
 Tops and side of legs
 Upper buttocks  Back of Arms
Rotate, Rotate, Rotate infusion sites
Check patient infusion sites at every appointment.
Quick‐set inserted and connected
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7/16/2014
Pods
Indications for Insulin Pump Therapy
Inability to normalize blood glucose levels with multiple daily injections
Recurrent hypoglycemia
Patient preference to normalize lifestyle
Motivated‐checking blood sugars 4 or more times a day
Taking multiple daily insulin injections
Pregnancy
Benefits of Insulin Pump Therapy
Improved glucose control potential
Less variation in blood glucose levels
Less injections
Potentially less frequent hypoglycemia
More flexibility with more normal lifestyle Improved sense of well being
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Risks Associated With Insulin Pump Therapy
 Infusion interruptions which can lead to hyperglycemia and ketoacidosis
 Infusion needle site reactions and/or infections
 Weight gain
 Pump failure
Candidate Evaluation
 Conducted by someone with a knowledge of pumps
 Evaluate current diabetes practices
 Beginning pump education
 Determine support system available
 Financial considerations
 Psychological considerations
Financial Considerations
Dependent on Insurance Company‐Insulin pumps and supplies fall under durable medical equipment(DME)
Maximum allowable vary by company
Financial implications: Out of pocket cost for an insulin pump is around $7000. Supplies are about $250‐300/month
 Insulin costs stay about the same
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Insurance Requirements
Insurance requirements vary but may include:
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Letter of medical necessity, signed by the prescribing provider
4 times a day blood sugar testing
Already on multiple daily insulin injections
Diagnosis of Diabetes for at least 6 months (dependent on insurance)
Completed a comprehensive diabetes education program
HbA1C greater than 7%
Medicare and Medicaid requires a fasting C‐Peptide and concurrent serum glucose and/or positive insulin antibody test.
‐c‐peptide must be <110% of lower limit or if renal disease < 200% of lower limit
‐fasting serum glucose < 225 or less, same time c‐peptide is done
For uninterrupted coverage of pump supplies Medicare and Medicaid require at least every 3 month appointments.
 BCBS recently added Type 2 coverage if the patient’s BMI is less than 35
 Insurances might require the patient be seen by a diabetes specialist or endocrinologist.
Patient Requirements
 Willingness and ability to do a minimum of 4 times a day blood glucose testing  Responsible and emotionally stable
 Willing to quantitate food intake
 Count carbohydrates/points/calories/exchanges
 Willing to keep regular appointments
 Good problem solver
Boluses
For Food intake and hyperglycemia
 Correction factor/Insulin Sensitivity
 Give when the blood sugar is elevated
 Amount one unit of insulin will decrease the blood sugar
 Use the 1800 Rule for calculating
Example of 1800 Rule: TDD of insulin 60 units
1800 divided by the TDD 60 units =30
1 unit of insulin will decrease the blood sugar by 30 points
Use 500 Rule for calculating carb ratios
Divide the TDD into 500 for carb calculation
Example 500 divided by 60 = 8.3 or 1 units will cover 8 grams of carb intake.
Can also give insulin boluses using the point system, calorie counting and exchange system
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7/16/2014
Prevention of DKA
 Monitor blood glucose at least 4 times a day
 When blood glucose is > 250 check urine ketones
 Use care when suspending the insulin pump
 Do not disconnect from the pump for > than one hour without replacing the insulin
 Change infusion needle site at least every 3 days
Treatment of DKA/Hyperglycemia
 Check ketones for all blood glucose > 250 mg/dl
Indicates a lack of insulin
 Give insulin correction bolus
By syringe if the ketones are positive
 Drink at least one cup of water per hour
If ketones are positive add ½ cup clear sugared liquids
 Change infusion needle Prevention of Site Abscesses
 Change site every 2‐3 days
 Aseptic technique
Wash hands
Use of alcohol, skin or IV prep pads to clean the skin
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7/16/2014
Disconnecting from the pump
 Indications: Contact sports, swimming, bathing
 Should not be disconnected for more than one hour
 Replace insulin lost by doing a bolus prior to or after disconnecting  Keep pump connected for a few minutes after replacement bolus has infused
 When off pump for 30 minutes the blood glucose starts elevating one mg/dl per every minute off
Supplies needed when away from home
 Blood glucose test strips
 Ketone test strips
 Alcohol swabs
 Insulin (Humalog, Novolog, or Apidra)
 Insulin syringe
 Pump cartridge/reservoir
 Infusion needle and tubing
 Alcohol, IV prep, or Skin prep pads
Supporting the child/adolescent pump wearer in the school setting
 Monitor and document blood glucose
 Check ketones when blood glucose is > than 250
 Look at the pump to be sure bolus is programmed and delivering.
 Assist with infusion site changes if needed
Wash hands
Clean skin with alcohol, IV prep or Skin prep pads
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7/16/2014
SUPPLIES NEEDED AT SCHOOL
 Blood glucose test strips
 Ketone test strips, good for only 6 months after opening
 Alcohol swabs
 Insulin (Humalog, Novolog, or Apidra)
 Insulin syringe
 Pump cartridge/reservoir
 Infusion needle and tubing
 IV prep, or Skin prep pads
One of the First Insulin Pumps
INSULIN PUMP BRANDS
Medtronic: Paradigm Revel or 530G
Animas: OT PING
Accuchek: Combo
Omnipod
T‐Slim
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7/16/2014
Medtronic Paradigm Pump
Revel or 530G
One Touch PING Insulin Pump
Accuchek Combo Pump
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7/16/2014
Omnipod: The Tubeless Insulin Pump
T‐Slim Insulin Pump
Continuous Glucose Monitoring
Dexcom G4 and Medtronic Enlite sensors
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7/16/2014
Continuous Glucose Monitoring Systems
 Enzyme coated sensor inserted into the subcutaneous tissue
 Relies on oxidation of glucose by glucose oxidase to 
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produce hydrogen peroxide, which is further oxidized producing electrons and generating measurable electric current
Senses glucose in interstitial fluid continuously (lag time from finger stick)
Averages and gives a numerical reading every 5 minutes
Customizable alerts that can be set to warn patients of impending hypo or hyperglycemia
Requires finger stick calibration
FDA approved for adjunctive use. Does not replace
fingerstick testing
Sensing glucose in interstitial fluid
Epidermis
Dermis
Reference
electrode should
sit beneath the
skin in
the Subcutaneous
Tissue
Subcutaneous
Tissue
Muscle
Glucose (mg/dL)
Fingerstick blood glucose monitoring in
the past….
300
200
100
0
0
20
40
60
80
100
120
Time (hours)
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What continuous glucose monitoring
can offer…
300
200
100
0
0
20
40
60
80
100
120
Time (hours)
Benefits & Barriers
Who will benefit?
 Motivated to improve glucose control
 Extremely insulin sensitive
 Frequent high or low BG
 Nocturnal hypoglycemia
 Hypoglycemia unawareness
 Fear of hypoglycemia
 Uncontrolled or erratic blood glucose
What are Common Barriers?
 Additional site to wear
 Minimal technical skills are required
 Must check BG prior to treatment
 Calibration
 Unrealistic Expectations
 Cost issues
 Overwhelmed with “too much” information
 Alarm “fatigue”
Important to look at monitor frequently and watch TRENDS, and NOT to Over‐React
Personal CGM Devices
Medtronic Paradigm Real-Time
& Guardian Real-Time
Real-Time
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7/16/2014
Dexcom Studio Reports
Medtronic Sensor Augmented Pump Dashboard 24‐hour visual analysis
SENSOR USE IN SCHOOLS
 Always verify sensor alarms with a fingerstick blood sugar check,  Silence alarm
 If sensor comes out at school, notify parent for replacement
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7/16/2014
Jackie Aday RN, BSN, CDE
Jeni Neighbors RN, BSN, CDE
Children’s Mercy Wichita Specialty Clinics
3243 East Murdock Street, Ste 201
Wichita, Kansas 67208
316‐500‐8900
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