(Continuous Subcutaneous Insulin Infusion - CSII)
The
Insulin Pump
- Definition -
the
constant, continuous infusion of a short-acting insulin
driven by mechanical force and delivered via a needle or
soft cannula under the skin
- Benefits
- More
predictable with fewer errors
- Allows for
adjustable boluses to cover ingested
carbohydrates
- Allows for
controlled adjustable basal levels of insulin to
cover (1) disparate levels of exercise (2) dawn
phenomenon and (3) fasting hypoglycemia
- Reduces
hyperinsulinemia and weight-gain
- Indications
- Failure of
intensive insulin regimens
- Dawn
phenomenon not amenable to nocturnal intermediate
insulin administered at bedtime
- Pregnancy
or desire thereof
- Recurrent
hypoglycemia
- Lifestyle
needs
- Patient is
compulsive and wants it
- Contraindications
- Lack of
monitoring compulsivity
- Low
socioeconomic status
- Lack of
constant dutiful support environment
- Lack of
intelligence
- lack of
maturity or educability
- Problems
- Pump stoppage for
any reason can lead to DKA in less than half a
day - therefore blood sugars must be monitored on
a regular basis
- Flow problems tend
to occur after changing infusion sets - to better
detect flow cessation change sets just before
giving a bolus as the problem should surface more
quickly.
- Infections at the
site of needle insertions can occur - to prevent
these the patient should scrub the skin well with
an antiseptic recommended by your team, change
the sites every two days, and make sure bacterial
carriers receive appropriate antibiotic therapy
- Pump therapy can
lead to hypoglycemic insensitivity - the patient
must therefore be appropriately informed and
allowed to target higher levels for
resensitization to occur
- How-to do it
- Utilize
Humalog or Velosulin
- Keep
activity level constant
- For the
initial guesstimate take the total pre-pump dose "x" and multiply it
by 80% = 0.8x
- Start
the basal rate at 50% of that (0.4x) and
divide it by 24 hours = (x/60)
units/hr
- Initially
divide the total carbs/day into 3 equal
meals and give 50% of the pre-pump dose
as three equal boluses of (0.4x/3)
= (x/7.5) units/meal
- If
no prior insulin history is known
guesstimate total dose by 0.44 times the
weight in kilograms
- For the
second titration adjust the basal rate from 2am
to 7am upward if the fasting sugar is higher than
the 3am sugar and downward if it is lower
- Adjust the
bolus for each meal based on a 90' post-prandial
glucose goal of 150 mg/dl
- Calculate
an insulin/carb ratio for each meal, then vary
the carbs
- Test
adequacy of daytime basal rates by missing a meal
and checking constancies
- Establish
an exercise/carb ratio for varying activities
- DO NOT
CHASE BLOOD SUGARS UNLESS YOU ARE SICK - ALLOW
PATTERNS TO BE ESTABLISHED AND VARY EITHER THE
BASAL OR INSULIN/CARB RATIOS
- Sick-Day Rules
- Guesstimate
your unit glucose excursion by dividing the total
insulin daily dose (tidd)
into 1500 or (1500/tidd)
- that is approximately the amount of glucose
lowering (in mg/dl)
afforded by 1 unit of insulin
- Monitor
blood sugar every 2-3 hrs
- Target
goal should be a blood sugar of 100 mg/dl and
supplemental boluses administered every two to
three hours by external syringe
- Check
ketones twice a day and if the blood sugar is
over 250 mg/dl the physician should be notified
if ketones are positive
- !!!If
vomiting or diarrhea impairs hydration in any way
go to the ER immediately!!!
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