CSII Continuous Subcutaneous Insulin Infusion

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CSII Continuous Subcutaneous Insulin Infusion

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Title: CSII Continuous Subcutaneous Insulin Infusion

1
CSIIContinuous Subcutaneous Insulin Infusion

The Insulin Pump
and
CGM
Continuous Glucose Monitoring
Kathryn Taylor Teare, MSN, CRNP, CDE
Medtronic Diabetes

2
Objectives

By the end of this program, the participant will
be able to
Calculate the carbohydrate content of a given
meal
Understand the pharmacodynamics of rapid-acting
insulin
Differentiate between basal and bolus insulin
Identify a patient who would benefit from an
insulin pump
Calculate baseline dosages for a given patient
Identify the benefits of continuous glucose
monitoring in the clinical setting

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CarbohydrateCounting
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What about Fiber?

A carbohydrate that is not digested
Fiber amounts gt 5 grams can be subtracted from
the total carbohydrate
1/2 cup cereal
27 grams carbohydrate
6 grams fiber
Subtract fiber grams for a total of 21 grams

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Quick Guide to Carb Counting
Fruit / juice ½ cup 15 grams
Starchy veggies ½ cup 15 grams
Non-starchy veggies ½ cup 5 grams
Bread 1 slice 15 grams
Pasta ½ cup 15 grams
Rice 1/3 cup 15 grams
Milk 1 cup (8 oz) 12 grams
Soda 1/2 cup (4 oz) 15 grams
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How much carbohydrate for me???

Age, Height, Weight, Sex
Activity level
Medication treatment plan
PREFERENCES
50 grams per meal- FEMALES (150 / day)
60 grams per meal- MALES (180 / day)

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Insulin
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INSULIN

Stimulates the entry of glucose into cells for
use as a source of energy
Inhibits the production of glucose from the
glycogen in liver or muscle cells
Promotes the storage of glucose as glucogen in
muscle and liver cells
Inhibits formation of glucose from
non-carbohydrates, such as amino acids
Stimulates the entry of amino acids into cells,
enhancing protein synthesis
Enhances fat storage and prevents the
mobilization of fat for energy

16
The Basal/Bolus Insulin Concept

Bolus Insulin (Mealtime or Prandial)
Limits hyperglycemia after meals
Immediate rise and sharp peak at 1 hour
10 to 20 of total daily insulin requirement at
each meal
Basal Insulin
Suppresses glucose production between meals and
overnight
Nearly constant levels
50 of daily needs
Ideally, for insulin replacement therapy, each
component should come from a different insulin
with a specific profile

17
Insulin Pump

Rapid-acting insulin is given continuously over
the 24 hours
Rates of infusion can be individualized
Mealtime and correction bolus as needed
Greater flexibility and glucose control for the
motivated individual

18
From Evolution to Revolution
Guardian iPro
1999
2003
2005
2007
2008
Continuous Glucose Monitoring Systems
Glucose Monitoring
Insulin Delivery
MiniMed, Paradigm, and Bolus Wizard, are
registered trademarks of Medtronic MiniMed, Inc.
System Gold and Medtronic CareLink are
trademarks of Medtronic MiniMed, Inc.
19
Insulin Used in Intensive Control Rapid-Acting

Human insulin analogues
Approved for treatment of diabetes with
intermediate and long-acting insulins or in CSII
Used as bolus insulin for meals / snacks and as a
basal insulin in CSII
Begin working in 5 minutes
Peak at 50-60 minutes
Half-life 2-2½ hours
Duration of action- 3-4 hours
NovoLog- Insulin Aspart
Humalog- Insulin Lispro
Apidra- Insulin Glulisine

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Who benefits from an Insulin Pumps

MDI
Flexibility
Significant fluctuations in blood glucose
Significant fluctuations in carbohydrate
ingestion
Cannot achieve goal A1c on MDI
Motivated individual
Good support system

21
Who should NOT be on a pump

Not willing to check blood glucose as at least
4-6 times a day
Altered mental status
Not willing to count carbohydrates
Not willing to treat hyper and hypoglycemia

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Insulin Pumps

Medtronic MiniMed Paradigm
Animas IR-2020 / Ping
Accu-chek Spirit
Insulet Omnipod
Solo

23
Case Study 1

Karen T. is an 18-year old female with Type 1
diabetes who had been on MDI for 3 years.
Current regimen
Lantus 25 units qhs
Novolog 5 units with meals
Her blood glucoses are running in the 200s.
She is to be started on an insulin pump
But where to start!!!!

24
Calculating Insulin Needs

Current Total Daily Dose (TDD) minus 25
or
0.5-1.0 units / kg of body weight
Adjust based on SBGM
Basal dose is 50 of TDD
Can vary 45-60
Bolus insulin dose is 50
Can vary 40-55

25
Calculating Insulin Needs

Determine TDD
Current TDD (40u) 25 (10u) 30 units
or
0.5-1.0 units / kg of body weight
60kg adult
Estimated TDD is 30-60 units
Adjust based on SBGM
Basal dose is 50 of TDD (15 units)
Can vary 45-60
Bolus insulin dose is 50 (15 units)
Can vary 40-55

26
Basal Rate

Suppresses glucose production between meals and
overnight
Basal dose / 24 hours
(15 units / 24 hrs .625 or .60 units / hour)
Adjust per SBGM
Basal needs vary throughout the day
Nocturnal hypoglycemia
Dawn phenomenon
Exercise / physical activity
Menstrual cycle
Illness

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Bolus dosing

Insulin to cover the carbohydrate content of the
meal
Insulin to return current hyperglycemia to target
blood glucose
Adjust for current hypoglycemia

30
Calculating Insulin CarbohydrateRatio
Amount of carbohydrate that 1 unit of insulin
will cover, bringing the blood glucose into
target range about 3-4 hours postmeal
31
Rule of 500

500 / TDD of insulin
Amount of carbohydrate that 1 unit of insulin
will cover, bringing the blood glucose into
target range about 3-4 hours postmeal
Rule of 450- May be more appropriate for those
who have more insulin resistance. Often used
with insulin pump

32
Rule of 500

500 / 30 16.67
Amount of carbohydrate that 1 unit of
rapid-acting insulin will cover, bringing the
blood glucose into target range about 3-4 hours
postmeal
InsulinCarbohydrate Ratio 117
Rule of 450- May be more appropriate for those
having more insulin resistance Often used with
insulin pump
450 / 30 15
InsulinCarbohydrate Ratio is 115

33
Insulin Sensitivity Factor
34
Insulin Sensitivity Factor (ISF) orCorrection
Factor

Amount of blood glucose reduction achieved by 1
unit of sq insulin
Used to return blood glucose to premeal targets
Rule of 1500
Rule of 1700
Rule of 1800

35
Rule of 1500

Developed by an endocrinologist
Best used for those with more insulin resistance
1500 / TDD
Adjust as needed
1500/30 50
Insulin Sensitivity Factor is 50
1 unit of insulin will lower the blood glucose by
50mg/dL in 3-4 hours

36
Rule of 1800

The Rule of 1500 was adjusted by a CDE insulin
pump specialist
Best used with rapid-acting insulin or those with
more insulin sensitivity
1800 / TDD
Adjust as needed
1800/30 60
Insulin Sensitivity Factor is 60
1 unit of insulin will lower the blood glucose by
60mg/dL within about 3-4 hours

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Determining the Correction or Supplemental
Doseusing the Insulin Sensitivity Factor
38
Correction or Supplemental Dose

Current blood glucose
Target blood glucose
ISF
CurrentTarget Amount above target
Amount above target / ISF
Correction dose of insulin

39
Correction or Supplemental Dose

Current blood glucose is 275
Target blood glucose is 100
ISF is 56 mg/dl
275 100 175
175 / 60 2.91
Correction dose of insulin is 2.9 units

40
Karens settings

Basal rate 0.60
IC Ratio 115
ISF 60
Target 90-120mg/dL

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Flexibility
42
Basal Rates

Suspend
Temporary basal
Basal patterns

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Basal Rates

Suspend
Exercise
Hypoglycemia
Bathing / swimming
Temporary basal
Exercise
Illness
Unexpected rise or fall in blood glucose

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Basal Rates

Basal patterns
Shift workers
Menstrual cycle
Weekend pattern
Regular change in activity
Travel
Exercise

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Bolus

Square / Dual Wave
(Extended / combination)
Bolus dose calculator
Carbohydrate data base
Bolus history
Time of day variations in bolus needs
Time of day variations in blood glucose targets
Calculation of active insulin (IOB)

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Glucose ManagementSoftware

Adherence- behavioral report. Are they using the
device as advised
Meter / Sensor - blood glucose and sensor
readings
Daily insulin use
Blood Glucose Log
Device Settings
On line

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CareLink
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CareLink
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CGMS

Glucose sensor
Transmitter / recorder
Glucose readings in the interstitial fluid are
measured continuously
Average of these measurements displayed every 5
minutes (288/day)
Calibrated at least twice a day
Greater accuracy with more frequent proactive
calibration

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Insulin Pump and CGMS
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The Sensor Catheter
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How does the sensor workThe 3 layers of the
sensor

Semi-permeable membrane
Glucose Oxidase
Platinum wire
The transmitter measures electrical current
caused by this breakdown of the hydrogen peroxide
(isigcurrent in nanoamps)
The more glucose in the more peroxide is formed
the more current is generated
Calibration assigns a blood glucose value to the
amount of current that is being generated

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Optimal Sensor Insertion
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I-PRO

Medtronic 3 day glucose sensor
Recorder is attached to sensor
Patient checks FSBG qid, and keeps a food diary.
Recorder and glucose meter readings downloaded
into a computer program
Reimbursed by Medicare and BC/BS

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IPRO- non diabetic
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I-PRO
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IPRO
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IPRO
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IPRO
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I-PRO

CPT codes
Continuous Glucose Monitor Study (3 days)
95250 Diagnostic study
95251 Interpretation
Reimbursement
Medicare- 156
BC/BS- 130
Allowed every 6 months
Cost of I-PRO system
Starter kit Recorder plus 10 sensors- 1300
Additional recorders- 900
Additional sensors- 35 each

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Special Populations

Children
Blindness
Elderly
Dementia

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Support SystemFamilies / Teachers/ Caretakers

Signs of hypoglycemia / hyperglycemia
Suspend / Disconnect
Treatment of hypoglycemia
Treatment of hyperglycemia
Use of a blood glucose monitor
Access medical assistance

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Hypoglycemia

Counting carbohydrates and bolusing correctly
Monitoring blood glucose
Increase the insulin carbohydrate ratio 1 unit
of insulin covers more carbohydrate
Decrease the basal insulin
Instruct on calculating correction carbohydrate
intake

74
Calculating Correction Carbohydrate Intake

Target blood glucose (100)
Pre-meal blood glucose (55)
ISF (60)
Insulincarbohydrate ratio (115)
Carbohydrate of IC Ratio (Rise in blood glucose
needed)
ISF
15 (45) Amount of carbohydrate that needs to
be ingested
60
11.25 or 12 grams

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Revenue Generation with Insulin Pumpsand CGMS

Patient training
Documentation of diagnostic testing meets
criteria for level 4 office visit
I-PRO
Procedure
Interpretation

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Putting it all Together

Case Studies

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Case Study 1

Karen T. is an 18-year old female recently
diagnosed with Type 1 diabetes.
Karen weighs 60kg
Her blood glucoses are running in the 200s.
She needs to be started on insulin
But where to start!!!!

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Karen T.

Teach carbohydrate counting
Encourage 60 grams of carbohydrate per meal (3
meals a day)
Start with TDD of 30 units
Basal rate 0.625
IC 115
ISF 60
Target 90-120

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Karen Ts Breakfast

Morning fasting pre-breakfast blood glucose is
180
Karen will be eating 60 grams of carbohydrate
Her goal blood glucose is 120mg/dl
She will use a rapid-acting insulin
60/15 4.0 units
60/601.0 units
Total dose 5.0 units

80
Karen Ts Lunch

Pre-lunch blood glucose is 135
Karen will be eating 60 grams of carbohydrate
Her goal blood glucose is 120mg/dl
She will use a rapid-acting insulin
60/15 4.0 units
15/600.25 units
Total dose 4.25 units

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Case Study 2David T.

David T. is a 56-year old male who has had Type 2
diabetes for 15 years.
He currently is taking a TZD, a sulfonylurea, and
metformin.
David weighs 100kg.
His blood glucoses are running in the 200s.
His CRNP wants to start him on insulin
But where to start!!!!

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Calculating Insulin Needs

0.5-1.0 units / kg of body weight
100 kg adult
Estimated TDD is 50-100 units
Adjust based on SBGM
Determine TDD
Basal dose is 50 of TDD (25-50 units)
Can vary 45-60
Bolus insulin dose is 50 (25-50 units)
Can vary 40-55

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David T.

Teach carbohydrate counting
Encourage 60 grams of carbohydrate per meal (3
meals a day)
Start with TDD of 50 units
Basal 25units/24 hours 1.05 u/hr
Now for the bolus doses

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David T.

Insulin Carbohydrate Ratio
450/50 units
1 unit insulin 9 grams carbohydrate
Insulin Sensitivity Factor
1700/50 34
1 unit of insulin will lower the blood glucose by
34mg/dl

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David Ts Breakfast

Morning fasting pre-breakfast blood glucose is
235
David will be eating 60 grams of carbohydrate
His goal blood glucose is 120mg/dl
He will use a rapid-acting insulin
60/9 6.7 units
135/343.4 units
Total dose 10.1 units

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David Ts Lunch

Pre-lunch blood glucose is 155
David will be eating 60 grams of carbohydrate
His goal blood glucose is 120mg/dl
60/9 6.7 units
35/34 1.0 units
Total dose 7.7 units

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Case Study 3Jackie

Jackie is a 58-year old female who has had Type 2
diabetes for 20 years.
She is currently is taking a TZD, metformin
Humulin 70/30, 20 units in the morning and 10
units in the evening.
Her most recent HgbA1c is 8.0
Jackie weighs 176 lbs (80kg) and is 54.
Her blood glucoses are running in the 200s.
Her CRNP wants to change her insulin regimen
What would you do?

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Calculating Insulin Needs