1. Advanced Pumping

2. 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

3. 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.

4. 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

5. Clinical Indications for Use of a Temporary Basal Rate Illness or infection Change in normal routine –Travel –Work Medications –Steriods Stress –Holidays –Exams Exercise

6. 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

7. 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

8. 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

9. 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.

10. 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

11. 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

12. Clinical Indications for Extended or Combo Bolus High post-prandial BGs despite accurate CHO counting Hypoglycemia immediately following meal Grazing, extended eating –Buffets –Holiday Meals –Parties –Movies

13. 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

14. 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

15. 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

16. 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%) Individuals response needs to evaluated

17. 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

18. 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

19. 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

20. Causes of Diabetic Ketoacidosis - DKA Inadequate or missed insulin dose Illness Infections Stress Infusion set or site issue Dehydration

21. 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

22. 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

23. 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

24. Activity In table teams, take 3 minutes to discuss your sick day management plans List plan on flip chart

25. 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