1. Newest Trends in Diabetes Management in Schools
Fran Melchionne, EdD,RN,CDE
BD Pediatric Diabetes Center
Goryeb Children’s Hospital

2. Agenda 1. Glucose monitors and CGMS 2. Nutrition Therapy
3. Basal – bolus insulin therapy
4. Injection technique
5. Insulin pumps

3. Objectives 1. Discuss the new trends in blood glucose monitoring
2. State 2 advantages of CGMS
3. Identify 2 methods to accurately count carbohydrates
4. Calculate a meal bolus and correction bolus for basal-bolus insulin therapy
5. List 2 responsibilities for an insulin pump at school

4. Glucose Monitors Trending with high and low patterns identified
Touch screens
Rechargeable batteries
Compatible with the iPod touch/iPhone

5. Insulinx Touch screen 3V lithium batteries
Can apply blood for up to 60 seconds
USB port to download reports
0.3 microliters of blood
20 – 500mg/dl results
Electronic logbook (insulin doses,exercise,etc)

6. Verio IQ Rechargeable battery Data/battery charging port
Cannot apply more blood to test strip
20 – 600 mg/dl
Stores 750 results
BS results must be within 3 hours of each other to determine a pattern
0.4 microliters of blood

7. iBG Star Rechargeable battery Compatible with iPod touch/iPhone
Can reports to diabetes team
Diabetes Manager App downloaded from APP store
0.5 microliters of blood
20 – 600mg/dl
Memory - 300

8. Continuous Glucose Monitoring
CGMS records BS levels every 5 minutes
Interstitial fluid BS
Glucose sensor is inserted under the skin
Contact sports should be avoided
Usually worn 3 – 5 days
Downloads reports
Patterns seen will result in changes in therapy

9. CGMS
Two types of iPro – placed by MD or pump patient with Medtronic Paradigm pump
Guardian – placed by patient, wears a monitor to display results
mySentry – remotely monitors blood sugar at night – used with Medtronic Paradigm pump
DexCom – placed by the patient, wears a monitor to display results

10. Nutrition Therapy Counting Carbohydrates Specific gram counting
Food measurement
Reading labels
Written resources – The Calorie King – Calorie, Fat and Carbohydrate Counter

11. Basal – Bolus Insulin Therapy
Lantus – basal insulin
Novolog/Humalog/Apidra – bolus insulin used for meal and correction boluses
Lilly HumaPen Luxura HD:can deliver ½ unit
Novo Junior Pen: does not deliver ½ unit only-will begin ½ unit dose at 1 ½ units of insulin
NovoFlex Pen and Lantus Solostar pen are disposable – 1 unit increments only

12. Basal – Bolus Insulin Therapy
Must do an “air shot” before each injection with a pen
BD smallest pen needle is the Nano – 32gx4mm
Injecting with a pen: inject at a 90 degree angle – no pinching needed – count to 10 and then withdraw the needle
Do not rub the injection site

13. Basal – Bolus Insulin Therapy
Injection by syringe: prepare the skin – pinch the skin using only your thumb and index finger – inject the needle at a 90 degree angle – wait 10 seconds and withdraw the needle
Pinching up with your entire hand may cause the injection into the muscle rather than subcutaneous tissue
Do not squeeze the skin tightly

14. Basal – Bolus Insulin Therapy
Insulin storage:
Unopened insulin is stored in refrigerator – do not freeze
Insulin pens in use must be refrigerated if temperature is >85 degrees
Insulin pens in use must be discarded 28 days after opening

15. Basal – Bolus Insulin Therapy
Insulin to carbohydrate ratios may be different for each meal
Corrections cannot be done less than 3 hours after the last bolus (meal or correction)
Targets vary for daytime and nightime
Lantus is usually given in the evening
If you treat a low BS before lunch and recheck the BS in 15 minutes, do not correct if BS is high

16. Basal – Bolus Insulin Therapy
Calculating a meal bolus:
If the insulin to carbohydrate ratio is 1unit of insulin for every 15 grams of carb……..
The child plans to eat 45 grams of carb for lunch = 45 divided by 15 = 3 units of insulin

17. Basal – Bolus Insulin Therapy
Calculating a correction bolus:
If the correction is 1 unit of insulin for every 50 mg/dl over target:
Child has a target BS at lunch of 100, takes BS and has 255……
Take the actual BS (255) – 100 (target) = 155mg/dl over target. Divide 155 by 50 = 3 units of insulin to correct BS of 255

18. Basal – Bolus Insulin Therapy
If in the example just given it was the same child who was going to eat 45 grams of carbohydrate for lunch and BS was 255 the insulin dose prior to lunch would be:
3 units for the meal bolus and 3 units for the blood sugar correction = 6 units of Novolog being given.

19. Insulin Pumps Insulin pumps: continuous subcutaneous insulin infusion
Many brands on the market
Features vary on each pump – child/family should choose what will work for them
Delivers basal insulin 24 hours a day
Will bolus for meal and corrections of BS

20. Insulin Pumps
Pumps are pager size devices that mimic normal insulin delivery
Uses only rapid acting insulin
It is an external device
Battery operated
Delivers insulin through a small teflon catheter

21. Insulin Pumps Insulin on Board is a feature of most pumps
The amount of insulin still active at a given time after a bolus
Advantages: decreases the risk of “stacking” insulin
May decrease risk of intentionally running high BS due to fear of hypoglycemia

22. Insulin Pumps
The pumps are able to track the insulin that is still working in the body from the previous bolus (meal or correction) and will subtract Insulin on Board from the next correction bolus calculation to prevent hypoglycemia

23. Insulin Pumps
I:C ratio, correction bolus, and target BS are entered into the pumps and when the carbs to be eaten and the BS are added … the pump will calculate the bolus to be given.
Carbs BG
IOB
Total

24. Pumping at School Diabetes Medical Management Plan
specific medical orders for medication, dosing, monitoring, carbohydrates and exercise
treatment of hypo/hyperglycemia
child’s ability to manage the pump
diabetes equipment needed at school

25. Pumping at School Parental Responsibilities:
Provide all equipment for diabetes care
Assess carbs for school lunches
Have emergency plan if pump malfunctions
Plan for pump when child is disconnected
Able to perform infusion set changes if needed or have alternate plan
Have a plan to insure all bolus doses are given

26. Pumping at School Pump Supply Kit
Infusion sets, meter and test strips, pump cartridges, insulin, pump batteries, ketone strips, glucose tabs or gel, glucagon kit, insulin syringes or pens

27. Pumping at School School Responsibilities: Follow medical plan of care
Provide for immediate treatment of low BS
Student can visit nurse as needed
Unrestricted access to fluids and restroom
Privacy to carry out diabetes care
Storage of all supplies
Notify all personnel child wears pump

28. Pumping at School School Responsibilities:
Provide training to all personnel on symptoms and treatment of hypoglycemia
Have back up plan in the event the nurse is not in the building

29. Pumping at School Hypoglycemia:
On the pump is treated as usual – 15 grams of carbohydrate, wait 15 minutes and recheck BS.
If BS is > 70 mg/dl no further action
If BS is < 70 mg/dl retreat as above
Mild to moderate hypoglycemia does not require the pump to be suspended or removed

30. Pumping at School
Severe hypoglycemia: unable to treat low BS without help, potential loss of consciousness, seizure activity …… need an emergency plan
Call 911
Give Glucagon
Notify parents/physician

31. Pumping at School Hyperglycemia without Ketones
Follow medical management plan
Check BG
Check ketones – negative
Give correction bolus for high BS
Drink water – 8 oz/30 minutes
Recheck BS in 2 hours

32. Pumping at School Hyperglycemia with Ketones
Follow medical management plan
Give correction bolus by INJECTION
Push fluids – 8 oz/30 minutes
Replace infusion set and cartridge
Recheck BS and ketones in 2 hours
Need to treat quickly to prevent DKA
Insulin injection every 2 hrs until cleared
Call parents/MD if moderate or large

33. Pumping at School
Infusion set issues: bent, crimped, dislodged or have fallen out
Insulin: ineffective
Site: could have infection
Tubing: air in tubing, make sure tubing is connected at infusion set and on pump

34. Pumping at School
Consider attending pump training with the student/family
Count carbs carefully
Perform or supervise BS testing per medical management plan
Test for ketones with BS> 300mg/dl
Hydrate for high BS
Adjust for activity with snacks or temporary basal rate

35. Pumping at School Pumps Animas Corporation – One Touch Ping
Medtronic Minimed – Paradigm Revel
Insulet – Omni pod (wireless)
Tandem Diabetes Care – t:slim

36. Thank you for your kind attention