Putting Your Patients on the Pump. Karen M. Bolderman

been delivered and training by the pump manufacturer (CDE trainer) can be scheduled. Another “order” is to designate who will “follow” the patient, i.e., adjust insulin doses during pump initiation, usually the first few weeks. You must decide if you will be in frequent communication with the patient during the initiation period, or if you prefer the pump company to manage this. Pump manufacturers may offer initial follow-up as a service provided by their staff or per diem CDE.

      Pump Supplies

      The initial pump order includes not only the insulin pump, but also the supplies necessary for the patient to get started. These include cartridges/reservoirs; infusion sets or pods; dressing/tape, such as IV 3000, skin prep, such as IV Prep, and battery. An initial pump order also includes user guide instructions, such as online tools, DVDs, and printed booklets.

      Most pump orders request a 3-month supply, so keep this in mind when completing the initial pump order or prescription. Consider that the cartridges/reservoirs and infusion set/pods will be changed every 1 to 3 days, so do the math. On the average, an infusion set is changed every 2 to 3 days; in one month, the pump user may need 10 to 15 cartridges/reservoirs and infusion sets/pods, and a 3-month supply may be a standard order. There may be more set and site changes initially as the new pump user may “lose” some sets during their learning curve. The same is true for the insulin. Remember that the tubing contains insulin, so when the patient changes their infusion set tubing, the insulin in the tubing is also discarded. One inch of tubing contains 0.3 to 0.5 units of insulin (depending on the brand of infusion set), so discarding 43″ tubing every 2 days results in a loss of over 250 units of insulin per month. Over time, some patients have learned to change only the actual infusion set base, leaving the tubing attached to their cartridge/reservoir until the cartridge is depleted. As of this publication date, the rapid-acting insulin analogs are FDA-approved for use in an insulin pump cartridge/reservoir for several days, including: Apidra®, 48 hours; Humalog®, up to seven days (three in the tubing); and NovoLog®, up to six days (sanofi-aventis 2009; Eli Lilly 2011; Novo Nordisk 2002–2011). But a decrease in efficacy, resulting in escalating hyperglycemia, can occur if the insulin remains in the cartridge/reservoir too long; cautionary advice is recommended. During initial pump starts, recommend patients “change everything” every 2 to 3 days. This will help patients to learn proper procedures and improve their technique, and will also eliminate the possibility of ineffective insulin as a cause of hyperglycemia. Refer to Infusion Site and Tubing Concerns in Chapter 6 for additional information.

      References

      American Diabetes Association: 2013 Clinical practice recommendations. Diabetes Care 36:S11–S66, 2013

      Eli Lilly and Company: Humalog (insulin lispro injection USP [rDNA origin]) for Injection Prescribing Information. Indianapolis, IN: Eli Lilly and Company, 2011

      Kaufman FR, Westfall E: Insulin Pumps and Continuous Glucose Monitoring: A User’s Guide to Effective Diabetes Management, Alexandria VA: American Diabetes Association, 2012