Adult Subcutaneous Insulin Pump On Line Resource Catherine Lai RN-BC CN III Project Mary M. Sullivan RN, MSN, ANP-BC, CDE Diabetes CNS

What is an Insulin Pump ? A subcutaneous insulin pump is a battery – operated device, designed to deliver insulin into the user’s body 24 hrs a day according to a preset program. The insulin pump continuously delivers a small amount of rapid acting insulin Aspart or Lispro at a basal rate to help the body to utilize the glucose that is in the blood stream at the time. A “bolus dose” of insulin can be given to cover the glucose that comes from the carbohydrates that the patient eats and/or to cover a high blood glucose level.

What is an Infusion Set ? The infusion set is a connection between the body and the insulin pump. The infusion set is composed of a cannula or needle, adhesive dressing, tubing and a connector to the pump cartridge. The infusion set is inserted subcutaneously. The infusion set is usually inserted in the abdomen, but can be placed in other locations, e.g. thigh, back of the arms or the upper buttocks.

Infusion Set Continued:

An insulin pump and infusion set. The infusion set is shown loaded into a spring-loaded insertion device (the blue object). A reservoir of insulin is shown attached to the set. .

supplied by UCSF hospital pharmacy Insulin for Pump Rapid acting insulin supplied by UCSF hospital pharmacy Lispro Insulin Aspart Insulin

Critical Points Because the pump uses a rapid acting insulin analogue (lispro or aspart), the patient is at risk for developing diabetic ketoacidosis if: the pump malfunctions the set dislodges or kinks the reservoir becomes empty The blood glucose level should be monitored: the patient is eating (before meals, bedtime, 2 am) The insulin pump should be disconnected from the infusion set for: - Mammograms - Bone density tests - Radiation treatment - CT scan - MRI - X-rays The infusion set can remain in place provided it is not metal. The Sure-T and the Detach Infusion set contain metal and must be removed prior to MRI.

Physicians Responsibilities The Primary team must contact Endocrine service, 443-9125 for an insulin pump plan evaluation. A patient may only use their own insulin pump if they are cognitively intact, demonstrate knowledge about pump operation and have been evaluated by Endocrine service. Endocrine service will give the patient form # (107-0033). ADULT GUIDELINES FOR USING YOUR SUBCUTANEOUS INSULIN PUMP WHILE IN THE HOSPITAL. The team will write orders on form # (105-0140). ADULT SUBCUTANEOUS INSULIN PUMP ORDER SET.

Insulin Pump Instructions: MD writes an order for: Insulin Pump Instructions: Insulin type Basal rate Carbohydrate ratio High glucose correction

Patient’s Responsibility The patient will need to supply his own infusion sets, reservoirs / cartridges and pump batteries. The patient must change and fill the pump reservoir and infusion set to insulin supplied by Hospital. The patient must change the infusion set every 72 hours or sooner if dislodged, if redness develops at the insertion site, or if unexplained hyperglycemia occurs (BG >300 mg/dL) x 2. The patient must not change pump settings without MD direction. The patient must not give boluses without RN supervision.

Adult Guidelines for Using Your Subcutaneous Insulin Pump While in Hospital form (107-0033). Endocrine service will give patient this form.

Pharmacy Responsibilities Pharmacy will supply the vial of LISPRO or ASPART insulin.

RN Responsibilities Procedure Check infusion site for redness or dislodgement of the infusion catheter every shift. 2. Verify and document the pump’s basal rate, carbohydrate ratio, and correctional insulin dose in U care.

RN Responsibilities continued: Documentation in UCARE

If the patient is unable to show the RN:  the basal rate RN Responsibilities continued: If the patient is unable to show the RN:  the basal rate  carbohydrate ratio  high glucose correction on the pump It is inappropriate for the patient to be on an insulin pump at this time. The team must be contacted to write appropriate orders to switch patient to Subcutaneous insulin or intravenous insulin infusion.

to change reservoir syringe if necessary. RN Responsibilities continued: 4. Verify the pump reservoir has enough insulin for 24 hours, the patient to change reservoir syringe if necessary. 5. Supervise boluses of insulin given via insulin pump by patient. 2 RN’s to check insulin vial supplied by hospital pharmacy. Primary RN will observe patient draw up insulin using a new reservoir syringe/set. 2 RN’s to check with any changes to pump settings ordered by MD. 6. Prevent Diabetic Ketoacidosis on the pump: BG >300 mg/dL x 2 Notify MD Ask the patient to change his infusion set.

7. Managing hypoglycemia on the Insulin Pump: RN Responsibilities continued: 7. Managing hypoglycemia on the Insulin Pump: BG < 70mg/dL. Notify MD Check BG Q15 minutes and repeat treatment until BG is > 100mg/dL. Patient is alert and can take PO:  Give 20 grams of oral fast acting carbohydrate per patient preference: e.g. 4 glucose tablets (5 grams glucose/tablet) or 6 oz fruit juice. Patient is not able to take PO but is alert:  Give 25ml of D50W IV push. Patient is incoherent/unconscious:  Give 25ml D50W IV push.  Temporarily disconnect pump tubing from the infusion set or turn off pump. 8. If insulin pump is discontinued, notify Endocrine Service at 443-9125.

Guidelines for transferring patient off insulin pump Contact Endocrine Service at 443-9125. Before taking a patient off an insulin pump the following must occur: Obtain an order for Subcutaneous insulin or Intravenous insulin infusion. The patient is at risk for DKA if the patient does not receive another source of insulin before pump is discontinued.

Risks of Pump Therapy Signs and symptoms of Diabetic Ketoacidosis and Hypoglycemia Diabetic Ketoacidosis Hypoglycemia BG > 300 Ketones in urine, blood Drowsiness Nausea Abdominal Pain Dry mouth Flushed skin Kussmaul respirations Polydipsea Polyurea BG < 70 Sweating Shaking Irritability Headache Paleness Confusion Seizure

Troubleshooting Hyperglycemia/hypoglycemia on pump therapy Causes: Actions: Insulin Pump: - Basal rate incorrect - Pump malfunction, suspended - Nurse to check rate and time, always review basal rate after any changes made Reservoir Syringe/cartridge - Empty cartridge - Leakage at luer lock - Not primed Patient to fill new cartridge, Patient to tighten connections Patient to prime infusion set Infusion Site: - Redness, irritation, inflammation, pain - Scar tissue - Nurse to check infusion site Patient to change infusion site if redness or irritation noted Infusion set: - Needle dislodged or cannula kinked - Air in infusion set or tubing Blood in infusion set - Patient to change infusion set and site Nurse to check for air in tubing Patient to disconnect from pump and prime air out of tubing Insulin: - Expired, cloudy - Lost potency - Obtain new insulin vial and change reservoir/cartridge

Carbohydrate Counting and Determining Insulin Dose Involves computing the number of carbohydrate grams in a given meal or snack. Allows patients on an insulin pump to calculate the right amount of insulin to counteract the corresponding blood glucose rise from their meal. To determine the amount of carbohydrate in a meal plan: Contact the dietitian to write the carbohydrate amount on patient menu. Look at the label for total carbohydrate and serving size.

Menu listing carbohydrate amount on each food items.

Calculate Insulin Dose for Carbohydrates Patient is on a carbohydrate ratio of 1 unit per 15 grams carbohydrates. Dietary department indicates on the patients food tray the amount of carbohydrates for each food item:   1 cup of rice 45 grams of carbohydrates 1 milk carton 15 grams  How much insulin does patient need for his carbohydrates? Total the amount of carbohydrates and divide by 15.  answer is 60/15 = 4 units for his carbohydrates. .

Review Questions 1. A patient arrives on your unit wearing an insulin pump, he is on a PCA pump and is drowsy and is not able to show the nurse his current pump settings. Can he/she continue to wear his pump? No, because the patient is not alert. The patient must demonstrate ability to manage his insulin doses on his insulin pump independently. Contact Endocrine 443-9125 to switch off pump and to get insulin plan set up for patient. 2. Which service needs to be contacted when a patient wearing an insulin pump arrives on your floor? Endocrine Service, 443-9125 3. How frequently does the patient have to change his infusion set? Every 72hr or sooner if patient has high blood glucose > 300mg/dL x 2, redness develops at insertion site or dislodgement of infusion catheter. 4. Where do you obtain pump supplies? Patient must provide own pump supplies. UCSF Hospital Pharmacy provides the vial of Lispro / Aspart Insulin.

References Information Source: Mary M. Sullivan, RN, MSN, ANP-BC, CNS Diabetes Additional Detailed Reference: UCSF Medical Center Nursing procedure – Use of Subcutaneous Insulin Pump (Adult) Author: Mary Sullivan, RN, MSN,CNS Diabetes – originated 07/08 UCSF Medical Center (Adult Subcutaneous Insulin Pump Order Set) 105-0140, (Rev 01/09). (Adult Guidelines for Using Your Subcutaneous Insulin Pump While in the Hospital) 107-0033, (Rev 12/08).