Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Advanced Pumping 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 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. 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 Clinical Indications for Use of a Temporary Basal Rate • Illness or infection • Change in normal routine – Travel – Work • Medications – Steriods • Stress – Holidays – Exams • Exercise 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 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 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 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. 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 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 Clinical Indications for Extended or Combo Bolus • High post-prandial BG’s despite accurate CHO counting • Hypoglycemia immediately following meal • Grazing, extended eating – Buffets – Holiday Meals – Parties – Movies 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 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 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 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%) • Individual’s response needs to evaluated 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 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 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 Causes of Diabetic Ketoacidosis - DKA • • • • • • Inadequate or missed insulin dose Illness Infections Stress Infusion set or site issue Dehydration 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 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 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 Activity • In table teams, take 3 minutes to discuss your sick day management plans • List plan on flip chart 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