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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 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 Feb 20, 2015 in Diabetes Management, Pump Therapy, Technology

Things to Consider when Upgrading your Insulin Pump

Things to Consider when Upgrading your Insulin Pump

– Lisa Foster-McNulty, RN, MSN, CDE

Every four years, we are asked to vote on who will become the next president.  If you wear an insulin pump, every four years your warranty will run. You get to exercise your right to continue with what is familiar – or jump over to something that is different and potentially a better choice for you! Either way, it’s not a decision to be made lightly. You’ll want to start thinking about this at least a few months before your warranty ends so that you have time to do your research. It can be helpful to have some idea of what points you’ll need to consider.

Do your Research

If you are very satisfied with your current pump, it may be a no-brainer to simply continue to use the same product. But what if you think that there may be something else out there that you’d prefer over your current pump? You can do some research and learn about the various pump options.

The manufacturers all have promotional packets that you can obtain from the company or the local rep, or perhaps from your endocrinologist or diabetes educator.  These packets give you detailed information about the pump and its features. Looking at these can be a great starting point from which you can make your own personal pro/con lists on each pump. If you have additional questions, a phone call to the company’s customer service line can be a useful way to gather additional information. It’s likely that you will quickly rule out several pumps and have just a few in mind that seem like they may be right for you.

Talk with Someone Using the Same Insulin Pump

Once you have narrowed your choices, you might want to talk to someone who is already using the pump to get their opinion of it. This can be done through online forums – or perhaps you can ask your endocrinologist’s office if they could put you in touch with another patient who would be willing to share their thoughts with you.

Ultimately you will have to decide which features are most important to you personally and which pump is the closest match to your needs. Many pumps can be returned within a certain time frame if they don’t provide what you expected; it’s best to ask about return policies prior to placing your order.

Things to Consider in an Insulin Pump

So which pump is the best fit for your needs?  Which requirements are on your must-have list?  Some points to consider are:

  • Tubing-free vs. tubing
  • Waterproof vs. not waterproof
  • The look and feel of the pump – the aesthetics
  • Integrated vs. separate blood glucose meter, as well as the accuracy of the meter
  • How discreet is it to use the pump?
  • Ease of use on a day-to-day basis (i.e. how many buttons need to be pushed to program a bolus, etc.)
  • Ease of downloading and interpretation of data
  • Dosing increments available
  • The amount of insulin the reservoir holds

Because insulin pumps can be expensive and co-pays/deductibles usually need to be met, cost is often a consideration. If the out-of-pocket cost is high, it might make more sense to choose a pump with a smaller up-front cost and more pay-as-you-use components in order to spread out the cost.

Is there a really promising new technology on the horizon that you might want to hold out for? You will be under warranty for four years and you may want to be able to upgrade when something new comes out. Find out if you will be eligible to upgrade for a reduced fee when new iterations of the pump come out. Once you’ve made your decision, contact the pump company and start the process of ordering the new pump. Your endocrinologist’s office can help with this if you need assistance.

Clearly there are many pump options and many points to consider. But with a little planning and thought, you can make a decision that is right for you!

Considering upgrading to the Omnipod insulin pump? Click here to get a FREE Demo and feel what it would be like to wear one.

Lisa Foster-McNulty, MSN, RN, CDE
Director of Patient Care and Education, Integrated Diabetes Services LLC

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In many cases, developing diabetes leads one towards a career in diabetes education. For Lisa Foster-McNulty, the opposite occurred. Lisa became a diabetes educator in 1995 while working in home healthcare and achieved CDE certification in 1998. She went on to lead the Home Care Network’s Diabetes Educator Team in 2000, before taking on a management role with an outpatient diabetes management program in a Philadelphia-area hospital system. A few years later, Lisa discovered that she would need to apply her clinical skills on herself when she was diagnosed with diabetes. When she and her husband decided to have a baby, Lisa chose to go on an insulin pump. Soon afterwards she began using a continuous glucose monitor and has been doing so ever since. Since 2008, Lisa has served as Co-Chair of the Education Committee for her local affiliate of the American Association of Diabetes Educators.

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Posted by on Jan 28, 2015 in Diabetes Management, Technology

A Look into the Diabetes Dark Ages

A Look into the Diabetes Dark Ages

I’m incredibly grateful to have access to diabetes technology and my current and future health has directly benefited from said technology. Diabetes technology isn’t always perfect and there are moments that I complain about it, LOUDLY, and there have been moments where I’ve come close to throwing my D-technology against the wall or out the window! Do I want quicker turnaround times for diabetes technologies and scientific breakthroughs?  You bet I do and I’ll absolutely fight for those technologies and scientific breakthroughs! BUT, I’ll never take diabetes-related technology/breakthroughs for granted, because I remember when diabetes technology (if you can even call it that) was downright archaic.

I was diagnosed with diabetes 37 years ago, at the tail end of the “Diabetes Dark Ages”, and it wasn’t easy. Back in 1977, the diabetes exchange diet was incredibly strict and inflexible. The ADA Exchange Diet poster hung from our kitchen wall (and directly behind my seat at the kitchen table) so that we could refer to and follow the exchanges to a T. Twelve grapes equaled one serving. A serving of strawberries was 1 cup and orange juice was 1/2 a cup. Most veggies were free foods, as were pickles and diet Jell-O. Baked potatoes were not a free food and were either small in size or served in halves, never wholes. Same goes for bananas.

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Diabetes and food became all about measurements and amounts – which isn’t a normal way for anyone to think about food. Diet JELL-O and pudding were dessert norms and really special occasions meant rainbow sherbet, except of course on my birthday, when I was allowed birthday cake, but only one slice. Counting carbs and insulin sliding scales weren’t around in the 70s and 80s, but I wish they had been!

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How Checking Blood Sugar Used to Work

Back then there was also no such thing as glucose meters or continuous glucose monitors (CGMs). Nope, back in the Diabetes Dark Ages we tested urine instead of blood. And it was pretty darn gross. The bathrooms doubled as science labs in the Kunik household.  The perimeters of our sinks and the back of our toilets were lined with glass test tubes sitting in their racks, and directly next to those racks sat a brown glass bottle of blue Clinitest® tablets. Those tablets fizzed a rainbow of colors when you mixed it with five drops of urine and 10 drops of water in a test tube. The glass test tubes became so incredibly hot as the Clinitest® tablet bubbled and fizzed that you could burn the tips of your fingers as you waited for the color that represented your “sugar” to be revealed.

Here’s a breakdown of how it all worked:

  • Blue=  Negative and meant that all was right in your world.
  • Teal Green=  Trace and it was darn near as good as blue and became my go-to color of choice.
  • Green Bean Green=  1% and wasn’t considered a “bad” result at all.
  • Putrid Green=  2% and I still get slightly stressed out whenever I see that color on the pantone chart.
  • Putrid Brown=  3% was a cause for panic and you could cut the tension with a knife.
  • Orange=  5% and meant both danger and non-compliance all rolled into one.

The “portable” version of Clinitest® tablets was called Tes-Tape®. Yep, it was portable, but it was no more accurate than then the Clinitest® color scale, which wasn’t really accurate at all.

Insulin Delivery

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By the time I was diagnosed, syringes had been upgraded from glass ones, that required boiling before every use for sterilization and sharpening by hand, to plastic disposable ones that that were far from their “ultra-fine” counterparts available today. Of course some habits die hard and my parents still boiled the plastic syringes in a little brown pot on the stove every time one of us needed to take our insulin. They would carefully remove the needles with the same tongs we used to flip bacon and that little light tan pot with the dark brown handle rarely left the stovetop.

The insulin we put in those syringes had names like Regular, NPH and Lente. To this day the only thing I know about Lente was that my dad used it, while my sister and I were NPH girls. When glucose meters finally made an appearance a few years later, they were incredibly expensive, took four minutes to calibrate every time you tested and neither the meter nor the test strips were covered by insurance.

I have a very vivid memory of my parents, my older sister and me being led to the back room of a special durable medical equipment pharmacy and being taught how to operate the meter that came with a 50-page instruction book.  The pharmacist explained how everything worked and my parents took copious notes – and I remember my mother breathing a sigh of relief when the pharmacist said that we could cut the strips in thirds in order to make them last longer. I wanted nothing to do with our family’s glucose meter, because of the incredibly painful guillotine/harpoon lancing device that was necessary to actually draw the large amount of blood each strip, whole or cut into thirds, required.

Original Insulin Pumps

Insulin pumps, while in existence were the size of VHS tapes and weren’t readily available. For years I would hear rumors of the mystical and magical insulin pump, but never actually saw one until I graduated from college.

Lack of a Diabetes Community

The Diabetes Dark Ages weren’t only limited to the science and treatment of diabetes, they extended into methods of communication and community, or lack thereof. My parents were basically on their own when it came to a diabetes support system and I don’t know how they did it, because they were completely alone. Now that I’m an adult, I appreciate what they did for me and my siblings – and I wish they were both still here so I could tell them face to face, instead of in a blog post.

“Communication methods” with my endocrinologist involved my amazing mom writing all my numbers (sugars) along with descriptions and measurements of every meal, and physical activity before and after each meal, down on a yellow legal pad and calling my endo’s office every couple of days. Then, slowly and methodically, she’d read the results to the person on the other end of the line. Within a few hours, the endo’s office would call back with changes to my insulin requirements. Sometime in the mid-/late-80s, my father purchased a fax machine for his home office and we started faxing our numbers in.

As for me, my “diabetes community” consisted of two older children in my area with type 1 – we acknowledged one another from time to time, but we didn’t really hangout because they were three years older than me. There was also my neighbor, one block over and across the street, who was a teenager and type 1 when I was diagnosed. I remember whenever I came over to play with her younger sister, she was always nice to me and asked me if I wanted a diet soda. But if I hadn’t attended the long-since-gone Camp Firefly in Spring Mountain, PA for two weeks every summer for three years (grades 4th through 6th), I never would have met any children my own age with diabetes. That camp and those friendships changed my life for the better.

Diabetes Technology Today

Today, diabetes is a different ballgame and people with diabetes have choices when it comes to managing it: MDI (multiple daily injections), a vast array of insulin pumps, pens, glucose meters and continuous glucose monitors that can be accessed in the cloud and insulins that are genetically engineered to work smarter and faster.

We also have access to Certified Diabetes Educators who can teach us all the tricks of the diabetes trade and we have access to an incredible Diabetes Online Community (the DOC) where we can find support, strength and comfort from one another 24/7, 365 days a year. As people with diabetes (PWDS), we must remember the Diabetes Dark Ages, so we can appreciate our diabetes present while fighting for our future, which may or may not include diabetes.

The Omnipod System advanced insulin pump technology with its tubeless design. Click here to order a free Demo to try it out yourself.

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