7. What is (are) your correction (or insulin sensitivity) factor(s)?
8. How do you treat hypoglycemia?
Hyperglycemia
Remind the patient that the pump uses only rapid-acting insulin, and if there is an unexpected or accidental interruption of basal insulin delivery or an inaccurate or missed bolus, hyperglycemia can occur. Other causes of hyperglycemia during pump therapy include infusion set issues, such as cracked or broken tubing or tubing that has become disconnected from the pump or infusion site; or leaving the infusion set in (or pod on) too long. Expired insulin, or insulin in the pump cartridge/reservoir that has been exposed to heat and become less effective, can lead to elevated blood glucose levels. Ignoring warnings or alerts for a low or dead battery, illness, stress, onset of menses, and a change in pump settings with time zone changes can also cause hyperglycemia.
You will be surprised (disheartened) at how many patients with type 1 diabetes are not familiar with ketones (cause, treatment, and prevention) and the use of ketone test strips. Educate your patients on the importance of obtaining ketone test strips, when to use them, and to make sure they periodically check their expiration date. Although ketone test strips are available over-the-counter, your patient may request or require a prescription for insurance reimbursement. Blood ketone strips require a meter. Now is a good time to provide a (new) prescription for a vial or pen of long-acting insulin. Also, make sure the patient has rapid-acting insulin readily available in case of infusion site or pump issues/malfunctions. Stress the importance of carrying a spare infusion set or pod. Many people find it upsetting to know they need to always carry their “emergency” or back-up “kit," but the first time a pump patient experiences severe hyperglycemia during pump therapy, they quickly appreciate the importance of being prepared.
Hypoglycemia
Education on hypoglycemia management includes a review of the causes, prevention, and treatment. A review of symptoms at this time is also helpful. Remind the patient that the insulin pump does not “think” and cannot prevent hypoglycemia. A miscalculated bolus dose (which can also be a result of inaccurate carb counting), “stacking insulin” (see Chapter 5), inaccurate basal rates, changes in pump settings due to time zone changes, and planned or unplanned exercise can cause hypoglycemia.
For mild to moderate hypoglycemia, teach and emphasize the Rule of 15:
• Treat hypoglycemia with 15 g fast-acting carbohydrate
• Check blood glucose after 15 minutes
• Repeat the treatment as needed
Every insulin-using patient should have a glucagon prescription. Instructions on its use should be provided to the patient’s family members, friends, and/or significant other(s) (including coworkers). This information should not be new to the patient or to the people around him or her.
Additionally, now is also a good time to review the importance of wearing easily visible medical identification. There are many choices, including inexpensive necklaces, bracelets, charms, and pendants for both women and men, as well as the option of more expensive and/or custom-made engraved medical jewelry. Again, this should not be new to the patient, but is often an overlooked yet very important factor in living with diabetes.
Infusion Set Insertion
The patient may have already observed the insertion and removal of an infusion set when deciding whether or not to try pump therapy (see Chapter 3, Pump Candidate Basics). If not, the patient should see a demonstration, and may benefit from a practice insertion, especially if s/he is anxious about inserting or wearing an infusion set. During pump start-up, the patient will learn how to prepare the skin and insert the infusion set. Pump manufacturer personnel also provide specific instructions and detailed information to pump patients about infusion set insertion procedures.
The abdomen is the preferred infusion site because it offers a consistent rate of absorption. However, pump patients have had success using other subcutaneous sites, e.g., the upper hip/buttock, thigh, and upper arm. Teach patients to avoid inserting the set within a 2-inch diameter of the navel, at the waistline or belt area, or in any area where clothing would rub against or constrict the site.
Infusion sets must be changed every 1–3 days (1–2 days for metal/steel and 2–3 days for Teflon or soft cannula) to prevent infection and scar tissue buildup, which can lead to occlusions and reduce or interrupt delivery of insulin. The site should be rotated every time the infusion set base or pod is replaced, usually from one side of the body to the other, and ½ to 1 inch away from a previous site. The patient must check the site at least once daily for redness, tenderness, and tape or dressing placement. Encourage patients with long-term diabetes, or those with possible long-term use and resultant scar tissue of their abdominal area from injections, to consider alternative subcutaneous infusion sites. Alternative sites include the upper arm, upper thigh, and upper buttocal area. Patients who have been using CGM also may have favorite injection sites and will have limited choices for pump infusion site placement. It is important to emphasize site rotation and adherence to frequent (2–3 day) site changes. You should check a patient’s infusion sites at every visit to be sure the patient is not developing lipohypertrophy, which often results from inadequate site rotation.
Patch/Pod Pump Infusion Set
Presently, a patch pump infusion set is of the soft cannula type and would be inserted similarly to an infusion set base that has connecting tubing. The self-adhesive tape for a pod pump has stronger adhesive to prevent dislodgement during activities or water exposure. Newer “modular type” models on the horizon may require only the infusion catheter to be replaced, allowing the pump pod to be reused and thus, reducing the expense of replacing the entire pod.
Steps for Infusion Set Insertion
1. Wash hands with antibacterial soap.
2. Assemble the infusion set supplies in a well-lit, clean workspace.
3. Prepare the infusion site using an antibacterial soap or solution or a commercial product, such as an IV Prep pad, Betadine pad, Betadine solution (iodine), or Hibiclens (chlorhexiden). Allow the skin to dry naturally. Anxious children and apprehensive adults may benefit from the use of a topical analgesic (including ice, a cold spoon, or a cold beverage can/bottle) to numb the skin before inserting the infusion set. Products to reduce discomfort from the infusion set base or pod insertion include over-the-counter creams, such as LMX4 and Numby Stuff, and a prescription cream called EMLA. Pump manufacturers can provide a list of commonly used skin prep products.
4. Follow the manufacturer’s instructions for the infusion set insertion and needle removal (if using a Teflon cannula set).
5. Secure the set/pod to the site with the sterile self-adhesive tape/dressing.
6. Follow the manufacturer’s instructions to attach the tubing and bolus insulin to fill the cannula.
A metal/steel needle set may be felt, whereas a Teflon cannula set will not. If a set becomes uncomfortable after it is in position, it should be removed and discarded, and a new one should be inserted in a different site. If the site becomes red, swollen, irritated, or painful, the patient should remove and discard the set and rotate the site. The set should also be changed if blood appears in the tubing.
Optional Saline Trial
An optional saline trial can be done with a loaner (or demo model) pump while patients are deciding whether a pump is the right tool for them or after the pump is purchased and delivered during the pump preparation period. A saline trial may help the patient decide which pump to choose (see Chapter 2). People who are unsure about “being attached to something 24 h a day” or have anxiety about infusion set insertion may find that wearing a pump with saline allays fears and concerns. A saline trial also provides the patient the opportunity to learn the functions of the pump (the “buttonology”)