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Posted by on Jul 10, 2017 in Pump Therapy, Technology, Tips and Tricks

High Blood Sugar due to Pump or Site Issues?

High Blood Sugar due to Pump or Site Issues?

Anyone who uses an insulin pump knows there are many benefits in terms of lifestyle and glucose control. However, there’s also a lot that can go wrong. Just the other day, I got one of those annoying “occlusion” alarms for no apparent reason. And last week, one of our patients developed pain at their infusion site and had to move to a different spot. Problems like these can result in high blood glucose (BG) levels. There are a number of “parts” that all have to be working properly for the pump to perform well. The insulin itself has to be at full-strength (unspoiled, and/or not expired), the reservoir and tubing have to be free of air pockets, the infusion set/cannula must be properly seated under the skin, the pump itself needs to be in good working order…you get the idea.

Pumps use rapid-acting insulin, which typically takes 3-4 hours to finish working. If something goes wrong, it is important to identify and fix the problem quickly. This requires good troubleshooting skills.  Otherwise, it is possible to have very high BG levels, produce ketones, become dehydrated, and slide headfirst into Diabetic Ketoacidosis (DKA). If you are on a pump and have unexplained hyperglycemia, you need to act fast.

Unexplained hyperglycemia can occur because of a “mechanical” issue related to the pump and its components. So how do you become an effective problem-solver? A little knowledge goes a long way.  Knowing whether an elevated BG is related to a pump issue or some other cause can help you resolve the problem in a timely and effective manner.

What to Do

If you have had an unusually high BG for several hours, it is important to test for ketones (either in urine or a blood sample). The presence of ketones indicates that your body is lacking insulin. Since the pump and its components may be part of the problem, there are three steps to take to help you figure out the possible problem and get back to a normal BG.

  1. Take an injection of rapid-acting insulin using a syringe or a pen to correct the high BG. That way, you’re absolutely sure that insulin has gotten into your body. If you have a tubed pump, you can disconnect a pump and deliver an equivalent bolus into the trash can (or sink) so that the pump can track the insulin-on board accurately.
  2. Change out everything: open a new vial of insulin, replace your Pod, or fill a new pump reservoir/cartridge and replace the infusion set and tubing.
  3. Drink plenty of water to prevent dehydration and to flush out the ketones through urination.

If ketones are not present, you can bolus with the pump. If your BG doesn’t come down within the next couple of hours, follow the three steps above. If it does come down, now is your chance to play detective and figure out what may have caused the high reading. Here’s a list of what I refer to as the “usual culprits:”

  • High BG can occur because of infection or illness, with hormonal changes such as menstrual cycles and growth spurts, following a low blood sugar treatment, or in relation to a change in some other medication–quite possibly one that is not related to diabetes. Steroids are infamous for raising BG levels. Stress and high fat foods can result in high BG levels, as can being too sedentary.
  • Insulin can “spoil” when exposed to heat or excessive agitation. Insulin needs to be stored properly, and care needs to be taken to keep the pump and tubing (if applicable) out of direct sunlight. Furthermore, rapid-acting insulin needs to be used in an insulin pump, so be sure that the wrong type of insulin wasn’t inadvertently used.
  • A site should not be used for any longer than 72 hours. Doing so invites the development of lipodystrophy, which leads to poor insulin absorption and results in high BG levels and a need for more insulin. Practice good site rotation to decrease change of developing scar tissue.

Identifying the Cause

  1. Check to be sure that the pump is delivering insulin as intended. Is the am/pm on the clock set correctly? Having them flipped can result in incorrect basal and bolus dosing. Has the pump been suspended for a while? Have the batteries died? Do you smell the insulin? If so, this indicates that something is leaking (the pump should be an airtight system). Check the connections to be sure they are tight and secure. It might look like the infusion set is in place, but the cannula could be blocked, kinked, or displaced.
  2. Be sure to take a good look at the infusion set and the insertion site. The adhesive on the infusion set should be well-secured to the skin. If it’s starting to lift up at the edges, it needs to be replaced right away. An adhesive product might need to be applied to the site and allowed to dry before you insert the new infusion set, to help it stick better. An overlay bandage could also be used, cutting a hole in the center so that you can still disconnect at the site. Of course, make sure you are not disconnected. If you have missed basal insulin, deliver a bolus to replace it. If you use a pump with tubing, be certain that any air is purged out. If there is a “window” that allows you to look at the placement of the cannula, check to make sure it looks like it was properly inserted. You should only see several millimeters of cannula in the window. If you see more, put in a new infusion set, being certain to insert the introducer needle all the way. Be sure that there’s no blood in the cannula or the tubing. If the insertion site is red, warm, or tender, insert a new infusion set in a different location.
  3. Check for a blockage. Pumps should alarm when a blockage occurs, but silent occlusions (minor blockages that do not trigger an alarm) can and do occur. However, if you do get an alarm, don’t ignore it. You should immediately change the reservoir/cartridge, tubing (if applicable) and infusion set. If occlusions occur often, try switching to a new site and location on your body or a different type of infusion catheter. A steel needle (as opposed to a flexible Teflon cannula) may do the trick. Or switch from a long cannula to a short one, or from a 90 degree to an angled infusion set, or vice versa. If the problem is due to the insulin crystallizing, a switch to a different brand of insulin may solve the problem.

There are a lot of “points in the pipeline” where a problem can occur with a tubed pump. One nice thing about the Omnipod System is that it eliminates (or minimizes) many of the potential issues. If you don’t have tubing, it reduces the likelihood of  air pockets or insufficient priming. The adhesive on Omnipod System also tends to be quite effective, so having the Pod fall off is less likely. Site evaluation with the viewing window is beneficial as you can see if the cannula has dislodged or if a leak is occurring (the window can become foggy or liquid-filled).

It would be great if technology worked the way it’s designed to 100% of the time, but it doesn’t.  Problems crop up, and being able to effectively troubleshoot lets you get back in range and spend as much time there as possible.

Gary Scheiner, MS, CDE

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Posted by on Jul 5, 2017 in Diabetes Management, Lifestyle, Pump Therapy

Independence Day and Firecrackers Galore

Independence Day and Firecrackers Galore

Everyone has a secret favorite holiday. When you think of favorite holidays, the usual suspects come to mind. Christmas is the leader for most because of the decorations and the gifts. (Eggnog? Not so much.) Thanksgiving and Easter usually follow behind because of their family and spiritual connotations, respectively, and then we start to get into slimmer pickings. Valentine’s Day is charming but can feel a little too commercialized; New Year’s Day seems like an excuse to recover from partying and get naps between football games. Labor Day is sad, really, the punctuation to summer and the last opportunity to wear white. But mixed in among those are the twin delights of Memorial Day and Fourth of July. Memorial Day signals the start of summer with all its warmth and potential, and then in the middle of summer, embedded in the heat, is the wild parade of the Fourth of July.

I love the Fourth of July. I love America, but more than anything, I love the community of celebration that gathers around the Fourth of July. People are going to have fun and they don’t care. Head to the lake and ride boats? Sure. Shoot off fireworks in the middle of the night? Why not?  Race to the amusement parks and ride screaming rollercoasters into the sun? Absolutely. Think about it: the Nathan’s Famous Hot Dog Eating Contest, an event built around dangerous levels of gluttony, is held on the Fourth of July. And it fits.

So what does this have to do with diabetes, you ask? A lot, actually. The day is memorialized around America gaining independence and marking its footprint in the world. That alone was brave, dangerous, and exhilarating. The activities I mentioned speak to the same sensibility, and Americans willingly partake in them. Diabetes, in a unique way, marks your independence in a dangerous but exhilarating manner. Having had Type I Diabetes for 24 years, this mentality is not one to easily embrace, but necessary to accomplish things in life. You are different. You live with a condition that can be difficult if not properly monitored and controlled. Like a rollercoaster. Like a boat ride. Like a firecracker. But if you do, it can bring you an amazing gratefulness for life and its many experiences. I have suffered through some terrible lows, literally and figuratively, during my time with diabetes. But I have achieved some amazing highs, and I will continue to, because I refuse to let the relentless drum of this disease defeat my indomitable spirit. I’ll fill up my Omnipod insulin pump and place it on, step out of the shadows and embrace the day. It will be a little dangerous, a little wild, but I will make it fun.

This year, for the Fourth of July, I took my two beautiful daughters to a parade and to watch fireworks. I checked my glucose levels but I still had burgers and ice cream like the rest. What about you?

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Posted by on Jun 26, 2017 in Lifestyle, Pump Therapy, Technology, Tips and Tricks

It’s Good to be STUCK! Strategies for Keeping Your Pump Securely in Place

It’s Good to be STUCK! Strategies for Keeping Your Pump Securely in Place

For those of us who use insulin pumps, we need insulin delivery to be seamless. Interrupted delivery can mean a major change in blood sugar, and it often happens at times when we are not prepared. While there are several reasons for interruptions, such as air bubbles in the tubing, periods of disconnection or insulin delivery suspension, it’s extremely frustrating when it happens because our insulin pump site doesn’t stay stuck to the skin. Shouldn’t that adhesive hold for at least three days?

Unfortunately everyone’s activity level and skin (and the oil it makes naturally) is a bit different. Some people have no issues with a site staying securely attached. In fact, they have to use something to loosen the adhesive in order to take it off! Others fight to keep it stuck even hours after a new site has been attached. Different times of the year such as summer can mean sweaty skin that decreases the adhesive quality of infusion sets or pod adhesive. Different activities (heavy exercise, a day at the beach, time in the pool) can also create adhesive challenges.

Where to Start

Surprisingly, one of the best strategies for keeping you pump site in place is to choose the right body part. Pods and infusion sets placed on the arms, legs (compared to the lower back and buttocks) are more likely to get bumped. The skin on the arms and legs (as well as the abdomen) also tends to perspire more, pull/stretch more, and have greater oil secretion. Likewise, hairless sites tend to hold in place better than hairy sites. So choose your body part wisely!

When placing a Pod or infusion set on your skin, make sure that the site is clean. Things like the natural oil in skin, moisturizers (lotions or moisturizing soap) as well as dirt can decrease the “stick” of the adhesive. Use an alcohol pad or soap and water to clean the site and then ensure that it is entirely dry.

Many options are available to help keep the adhesive in place, and remove it when it’s time.

Skin Preparation and Adhesive Removal Products

Some people use Antiperspirant (solid or spray instead of the cream or gel type). Put it on the skin where the infusion set will be placed and wait until the area is completely dry before attaching the infusion set/Pod.

There are sticky products like IV Prep (which cleans the oil from the skin and makes the skin sticky which helps the site stay attached). There are also products like Mastisol or Skin Tac which are kind of like a rubber cement for skin. When placed on the skin before the infusion set is inserted, they help to make a barrier to prevent the skin’s oils from loosening the adhesive. These are very sticky and usually require a product like Detachol to remove the site from the skin. Another alternative for easy removal is to soak a cotton ball in baby oil, dab it around the adhesive and let sit for a few minutes before pulling off the Pod or infusion set.

Tape

Some tapes are a bit like a thin plastic tape, but will fit over or under the Pod or infusion set adhesive to keep it securely attached.  These thin tapes can be used under the Pod or infusion set and will allow the set to be inserted through the “tape,” create a barrier (which can help those with skin allergy to the Pod or infusion set adhesive as well as keep it stuck), and keep the site intact.  These include:

Hypafix, Opsite Flexifix (by Smith and Nephew), Tegaderm, and IV3000. Another good option if you have skin allergies is ToughPads by Johnson and Johnson.

These types of tape can also be used over the top of the Pod or infusion set adhesive, if needed.  Smith & Nephew’s Infusion Set IV 3000 is popular because it has a pre-cut hole to allow access to the infusion set’s disconnect mechanism.

Other types of tape are a bit more like fabric and some come pre-cut in fancy shapes and designs to make your pump site a bit more fun and less “medical” looking. These include:

  • RockaDex
  • Kinesiology tape or Rocktape (not pre-cut, but available through local pharmacies in a roll with many colors available that you can cut to the size and shape you need for your product).
  • GrifGrips have excellent adhesive quality, stylish designs, and pre-cut holes that are custom-sized for Omnipod, CGM transmitters, or traditional pump infusion sets.

Granted, there are about as many products available for keeping that site stuck as there are skin types. It often takes some trial and error to find the product that works best for you. But keeping yourself connected is well worth it!

-Gary Scheiner MS, CDE and the Clinical Team at Integrated Diabetes Services

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Posted by on Jun 19, 2017 in Pump Therapy, Tips and Tricks

Preventing and Managing Pump Failures

Preventing and Managing Pump Failures

Technology: can’t live with it, can’t live without it. It’s great when it works like it’s supposed to, but when it doesn’t, it can be a huge source of frustration! Dangerous fluctuations in blood glucose (BG) and potentially serious changes to our health can occur when technology fails. So the more we can be prepared to take quick and effective action, the better off we are.

Despite the best efforts of insulin pump manufacturers to produce high-quality, reliable products, occasional problems can still occur. But as pump users, there is a lot we can do to minimize pump-related problems.

Daily maintenance

  • Change your pump/infusion set at least every 72 hours.
  • Evaluate unexplained high BGs in a timely fashion:
    • Check your infusion site at least once a day for redness, inflammation, warmth, and loose adhesive. Change immediately if any problems are detected.
    • Promptly purge any bubbles in the tubing if necessary. Use room temperature insulin to keep air bubbles to a minimum.
    • With unexplained high readings, take corrective doses via injection rather than with the pump. If the injection doesn’t bring your BG down, switch to a new insulin vial.
  • Do not suspend insulin delivery or disconnect pump for more than 90 minutes without replacing missed basal insulin on an hourly basis.
  • Change or charge your battery upon first alert.
  • Change or fill your insulin reservoir at the first alert.

Be vigilant and check for problems on an ongoing basis so they can be detected at the earliest possible time. Pumpers are more vulnerable to ketones and Diabetic Ketoacidosis (DKA) due to the absence of a long-acting insulin.

If you are switching over to a new pump, be certain that all of your settings are transferred over correctly. Evaluate your records on an ongoing basis to be sure your settings work effectively for you, and get help if they don’t.

Mechanical pump failure

There’s nothing more frustrating than getting an alarm telling you that there is a serious problem with your pump; it’s analogous to the “blue screen of death” on a computer. When this happens, call the pump manufacturer right away to troubleshoot, and start the process of getting a replacement pump if necessary.

Remember that your pump is a sensitive piece of equipment. Know what the manufacturer’s recommendations are for keeping the pump clean. Most pumps can be wiped with a damp, lint-free cloth. Do not expose it to cleaning products or harsh solvents. Also, check whether your pump can withstand exposure to things like x-rays, airport security equipment, MRIs, and sudden drops (such as on an amusement park ride).

Keep your pump away from moisture if it’s not waterproof. The Pods in the Omnipod System are waterproof*, but the PDM is not. Other pumps on the market have varying degrees of resistance to moisture. If you wear a tubed pump next to your skin, be sure the buttons face away from your body.  Moisture from perspiration can lead to pump failure, particularly if there is a break in the pump’s casing.

Consider keeping your pump in a case that will protect it if it’s inadvertently dropped. If it is dropped, do a careful inspection, noting any scratches, cracks, or other damage. If you find anything wrong, contact the pump manufacturer immediately. Most will send you a new pump overnight, provided your pump is under warranty.

Plan for a pump failure

  • Keep a vial or pen of long-acting (basal) insulin in your refrigerator as an insurance policy.
  • Talk to your healthcare providers in advance so you know how much basal insulin to take via injection, and have a plan for temporarily switching over to Multiple Daily Injections (MDI) if you have to take a break from using your pump.
  • Ensure you have necessary syringes or pen needles available.
  • Have ratios written down to calculate how much insulin to take for a correction, food and how much insulin you have on-board following a bolus injection.
  • Keep phone numbers for your providers someplace where they are easy to find, and share this information with your loved ones in case they need to help you.

Maintain a printed list of your current pump settings someplace where you can quickly put your hands on it. You will need this list of pump settings to program the new pump when it arrives. This includes basal settings, Insulin to Carbohydrate Ratio (I:C), sensitivity/correction factor, active insulin time, target BG, maximum bolus, maximum basal rate, etc. If you download your pump regularly, you can also check your download for the last settings that were active.

As the saying goes, an ounce of prevention is worth a pound of cure. If you have a solid plan in place, it’s a lot easier to stay out of trouble and get back on track.

*The Pod has a waterproof IPX8 rating for up to 25 feet for 60 minutes. The PDM is not waterproof.

-Gary Scheiner, MS, CDE

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