Remember pump problems can occur anytime but especially at night or when you first start a new pump site. Always check your blood sugar at start of a new pump site and recheck in 1‐2 hours to make sure that blood sugars are not rising rapidly. Remember pump problems can occur anytime but especially at night or when you first start a new pump site. Always check your blood sugar at start of a new pump site and recheck in 1‐2 hours to make sure that blood sugars are not rising rapidly.

Remember pump problems can occur anytime but especially at night or when you first start a new pump site. Always check your blood sugar at start of a new pump site and recheck in 1‐2 CORRECTION INSULIN (Humalog or Novolog or Apidra) hours to make sure that blood sugars are not rising rapidly. (Use syringe or insulin Pen) Insulin Pump

CORRECTION INSULIN (Humalog or Novolog or Apidra)

(Use syringe or insulin Pen)

Program

Blood sugar 150 ‐ 200: ___ units CORRECTION INSULIN (Humalog or Novolog or Apidra) Blood sugar 201 ‐ 250: ___ units Blood sugar 150 ‐ 200: ___ units(Use syringe or insulin Pen) Blood sugar 251 ‐ 300: ___ units Blood sugar 201 ‐ 250: ___ units Blood sugar 301 ‐ 350: ___ units Blood sugar 251 ‐ 300: ___ units Blood sugar 351 ‐ 400: ___ units Blood sugar 150301 ‐ 200:350: ___ units Blood sugar >400: ___ units Blood sugar 201351 ‐ 250:400: ______units units

Blood sugar 251>400: ‐ 300: ______units units OR Blood sugar 301 ‐ 350: ___ units

ALTERNATE WAYBlood TO CALCULATE sugar 351 ‐ CORRECTION400: ___OR units INSULIN:

Take current bloodBlood sugar sugar reading >400: ______and unitssubtract blood sugar target of ___ divide by sensitivity of ALTERNATE___ to get your WAY correction TO CALCULATE dose for CORRECTION high blood sugar. INSULIN:

Take current blood sugar reading _____ and subtract blood sugar target of ___ divide by sensitivity of ___[For toexample: get your correction dose for high ORblood sugar. Blood sugar of 350 minus target blood sugar of 100 divided by sensitivity of 50 equals 5 units of insulin (Humalog or Novolog or Aprida) ALTERNATE[For(350 example:‐100/50=5 WAY units)] TO CALCULATE CORRECTION INSULIN: Blood sugar of 350 minus target blood sugar of 100 divided by sensitivity of 50 equals 5 units of insulin Take(Humalog current or Novologblood sugar or Aprida) reading _____ and subtract blood sugar target of ___ divide by sensitivity of (350___ to‐100/50=5 get your units)]correction dose for high blood sugar.

[For example: Blood sugar of 350 minus target blood sugar of 100 divided by sensitivity of 50 equals 5 units of insulin (Humalog or Novolog or Aprida) (350‐100/50=5 units)]

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Insulin Pump Safety Plan

Anytime your blood sugar is over 300 mg/dl, check ketones! Green Zone (Safe) Blood Sugar under 300mg/dl

What to do:  Continue basal insulin through insulin pump! Use pump for bolus insulin needs, carbohydrate and high blood sugar coverage.

Yellow Zone (Caution) Trace or Small Ketones

What to do:  Continue basal insulin through the insulin pump. Britney Frazier, MD Barbara Thompson, MD  Give insulin bolus through pump for high blood sugar. DO NOT eat, just give insulin for high blood sugar  Recheck blood sugar in 1 hour o If blood sugar is lower at the 1 hour check (by more than 30 mg/dl) safe to use pump. o If blood sugar does not drop by at least 30 mg/dl then go to red zone  Check ketones in 3‐4 hours to make sure they have cleared  Drink lots of water (8‐12 ounces hourly)

Red Zone (Danger!) Moderate or Large Ketones

What to do:  STOP USING INSULIN PUMP FOR BOLUS NEEDS!  GIVE CORRECTION INSULIN WITH SYRINGE OR PEN DEVICE!  DOUBLE THE CORRECTION INSULN FOR MODERATE OR HIGH KETONES  Place new insulin pump site and continue basal insulin through Gad Kletter, MD Katherine Philla, MD pump.  Continue to give insulin by syringe or pen device every 2‐3 hours until ketones cleared AND Blood sugar under 200 mg/dl  Drink lots of water (8‐12 ounces hourly)

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Pre Pump Review Questions Pre Pump Review Questions

Pre Pump Review Questions 1. Insulin pumps are used to deliver which type of insulin? 1. Insulin pumps are used to deliver Pre which Pump type Review of insulin? Questions

1. Insulin pumps are used to deliver Pre which Pump type Review of insulin? Questions A. Lantus Pre Pump Review Questions 1. InsulinA. Lantus pumps are used to deliver Pre which Pump type Review of insulin? Questions B. Levemir 1. InsulinB.A. LevemirLantus pumps are used to deliver Pre which Pump type Review of insulin? Questions Pre1. InsulinC. PumpNovolog/Humalog pumps Review are used to Questions deliver which type of insulin? 1. InsulinA.C.B. LantusNovolog/HumalogLevemir pumps are used to deliver which type of insulin? D. All of the above 1. InsulinB.D.C.A. LevemirAllNovolog/HumalogLantus pumps of the areabove used to deliver which type of insulin? 1. Insulin pumps are used to deliver whichA. Lantus type of insulin? C.D.A.B. Novolog/HumalogAllLantusLevemir of the above 2. TheB. smallLevemir amount of insulin delivered automatically and continuously by the pump is called? A. Lantus 2. TheD.C.B.A. smallAllNovolog/HumalogLevemirLantus of amount the above of insulin delivered automatically and continuously by the pump is called? C. Novolog/Humalog B. Levemir 2. TheD.C.B. smallAllNovolog/HumalogLevemir of amount the above of insulin delivered automatically and continuously by the pump is called? As part of your Insulin Pump Start you will be expected to complete the following: A.D. BolusAll of the above C. Novolog/Humalog 2. TheA.D.C. smallBolusAllNovolog/Humalog of amount the above of insulin delivered automatically and continuously by the pump is called? B. Basal D. All of the above 2. TheB.A.D. smallBasalBolusAll of amount the above of insulin delivered automatically and continuously by the pump is called? DATE INITIALS PROCEDURE 2. The small amount of insulin delivered automatically and continuously by the pump is called? 2. TheB.A. smallBasalBolus amount of insulin delivered automatically and continuously by the pump is called? (Educator) 3. The insulin delivery used to cover for food, or to correct a high blood glucose is called what? 2. The small amount of insulin delivered3. 2. TheB.A. insulinsmall BasalBolusautomatically amount delivery andof used insulin continuously to coverdelivered for by food,the automatically pump or to is correctcalled? and acontinuously high blood glucose by the pumpis called is called?what? A. Bolus Meet with a dietician to assess carbohydrate counting 3. TheB.A. insulinBasalBolus delivery used to cover for food, or to correct a high blood glucose is called what? A. Bolus A.B. BolusBasal within the last 3 months. 3. TheA.B. insulinBolusBasal delivery used to cover for food, or to correct a high blood glucose is called what? B. Basal B. Basal Attend a pre pump appointment to review pump therapy. 3. TheB.A. insulinBasalBolus delivery used to cover for food, or to correct a high blood glucose is called what? 3. The insulin delivery used to cover for food, or to correct a high blood glucose is called what? Meet with insulin pump vendor to do a saline trail 3. TheB.A. insulin BasalBolus delivery used to cover for food, or to correct a high blood glucose is called what? 3. The insulin delivery used to cover4. Insulin for food, pump or to users correct should a high check blood their glucose blood is called glucose what? a minimum of how many times per day? Present blood sugar logs from the last 90 days showing 4. 3. InsulinTheB.A. insulinBasal Bolus pump delivery users should used to check cover their for food, blood or glucose to correct a minimuma high bloodof how glucose many is times called per what? day? A. Bolus A. Bolus 4. InsulinA.B. BolusBasal pump users should check their blood glucose a minimum of how many times per day? test of 4 times daily minimal (most insurance require this) A.B. 1Basal‐2 B. Basal 4. InsulinA.B. 1Basal Bolus‐ pump2 users should check their blood glucose a minimum of how many times per day? As soon as your pump arrives you will need to do training B. 4 ‐6 4. InsulinB.A. 41 Basal‐ pump62 users should check their blood glucose a minimum of how many times per day? either online or through training packets provided by 4. InsulinC. 8‐ pump10 users should check their blood glucose a minimum of how many times per day? 4. Insulin pump users should check4. Insulin theirC.B.A. 841 blood‐ pump1062 glucose users shoulda minimum check of howtheir many blood times glucose per day?a minimum of how many times per day? pump company. If this is not done prior to pump start D. When you don’t feel well 4. InsulinD.C.B.A. When841‐ 10pump62 you users don’t should feel wellcheck their blood glucose a minimum of how many times per day? appointment, you will be asked to reschedule A. 1-2 E.A. Every1‐2 hour E.D.C.A.B. EveryWhen814‐1026 houryou don’t feel well appointment. B. 4-6 B. 4‐6 E.D.B.C.A. Every When481‐6102 houryou don’t feel well Call clinic as soon as pump arrives for appointment. Attend C. 8-10 5. I needC. 8 ‐Basal10 insulin throughout the day even if I choose not to eat. 5. I needE.C.D.B. Every8When4 ‐Basal106 hour you insulin don’t throughout feel well the day even if I choose not to eat. D. When you don’t feel well D. When you don’t feel well the pump start training in the Tacoma office. 5. I needD.E.C. WhenEvery8 ‐Basal10 houryou insulin don’t throughout feel well the day even if I choose not to eat. Follow up with diabetes educator 2‐3 days in Tacoma E. Every hour E. Every hour 5. I needA.E.D. TrueEvery When Basal houryou insulin don’t throughout feel well the day even if I choose not to eat. following your pump start 5. I needA.E. True Every Basal hour insulin throughout the day even if I choose not to eat. 5. I needA.B. TrueFalse Basal insulin throughout the day even if I choose not to eat. Follow up with your provider in 2 weeks after pump start5. Ineed Basal insulin throughout5. the I needB. dayFalse evenBasal if insulinI choose throughout not to eat. the day even if I choose not to eat. B. False 6. 5. BeingI needA. True on Basal a pump insulin will throughout mean that the I won't day evenhave ifanyI choose more BG nothighs to eat. or lows If using a sensor, will need appointment for sensor start 2‐ A. True 6. BeingA. True on a pump will mean that I won't have any more BG highs or lows B. False 4 week after pump start, in Tacoma office B. False 6. BeingA.B. TrueFalse on a pump will mean that I won't have any more BG highs or lows A.B. TrueFalse Attend an advanced pump class/automation start 6. BeingA. True on a pump will mean that I won't have any more BG highs or lows B.A. FalseTrue appointment within 3‐6 months of pump start 6. Being on a pump will mean that 6. IBeing won'tB.A. FalseTrue onhave a pumpany more will BG mean highs that or lowsI won't have any more BG highs or lows 6. BeingB. False on a pump will mean that I won't have any more BG highs or lows 6. BeingA.B. TrueFalse on a pump will mean that I won't have any more BG highs or lows A. True A. True 7. 6. HowBeingB. oftenFalse on a pumpshould will the mean infusion that site I won't be changed? have any more BG highs or lows B. False 7. HowA.B. oftenTrueFalse should the infusion site be changed? A. True 7. HowB. oftenFalse should the infusion site be changed? I ______, parent/guardian of ______7. How often should the infusion siteB.A. be changed?FalseTrueDaily 7. HowA. oftenDaily should the infusion site be changed? B. FalseEvery 2‐3 days 7. HowA.B. oftenDailyEvery should2‐3 days the infusion site be changed? Have read, understand and agree to the standards and protocols noted above. A. Daily 7. HowC. oftenEvery should4‐6 days the infusion site be changed? 7. HowA.C.B. oftenDailyEvery should42‐63 days the infusion site be changed? B. Every 2-3 days D. Once a week 7. HowB.D.C.A. oftenEveryOnceDaily ashould24 ‐week36 days the infusion site be changed? Tweens and Adolescents (age 10 and up) Signature C. Every 4-6 days A. Daily C.D.A.B. EveryOnceDaily a42 ‐week63 days D. Once a week 8. WhenB. Every on a 2pump‐3 days I will 8. WhenD.B.C.A. OnceEveryDaily on a a 24pump ‐week36 days I will ______C. Every 4‐6 days 8. C.D.B. EveryOnce a42 ‐week63 days When on a pump I will D.A. Oncebe able a weekto throw out all my injection supplies, and it won't matter if I forget how to do D.C.A. OnceEverybe able a4 ‐ weekto6 days throw out all my injection supplies, and it won't matter if I forget how to do Additional Caregivers Signature multiple daily injections A. be able to throw out all my injectionD. Oncemultiple supplies, a week daily and injections it won't matter if I forget how to do multiple daily B. still need to keep my injection supplies, and remember how to do multiple daily injections, injections B. still need to keep my injection supplies, and remember how to do multiple daily injections, ______Relationship to patient as a backup B. still need to keep my injection suppas alies, backup and remember how to do multiple daily injections, as a backup C. still need to inject for meals, but the pump will take care of my insulin needs between meals ______Relationship to patient C. still need to inject for meals,C. but stillthe pumpneed towill inject take care for meals,of my insu butlin the needs pump between will take meals care and of duringmy insulin needs between meals and during the night the night and during the night D. still need to inject once or twice a day to keep my blood glucose levels steady between ______Relationship to patient D. still need to inject once or twiceD. stilla day need to keep to inject my blood once glucose or twice levels a day steady to keep between my blood meals, glucose but the levels steady between meals, but the pump will give me insulin for my meals pump will give me insulin for mymeals, meals but the pump will give me insulin for my meals

2 9. A bolus that is given to treat a high blood sugar is called7 9. A bolus that is given to treat a high blood sugar is called

A. Carbohydrate bolus A. Carbohydrate bolus B. Correction/Sensitivity bolus B. Correction/Sensitivity bolus

10. I use the Insulin to carbohydrate ratio (ICR) to calculate: 10. I use the Insulin to carbohydrate ratio (ICR) to calculate:

A. How much insulin to take when I eat A. How much insulin to take when I eat B. How much bolus is required to correct high blood glucose B. How much bolus is required to correct high blood glucose

11. Rapid acting insulin works for up to _____ hours after it is injected? 11. Rapid acting insulin works for up to _____ hours after it is injected? A. 1‐2 A. 1‐2 B. 3‐5 B. 3‐5 C. 6‐8 C. 6‐8 D. 12‐24 D. 12‐24

12. What area should you avoid when inserting an infusion set? 12. What area should you avoid when inserting an infusion set?

A. Upper Thighs A. Upper Thighs B. Stomach area B. Stomach area C. Waistline/Belt area C. Waistline/Belt area D. Upper Buttocks D. Upper Buttocks

13. Is an insulin pump wearer have a higher risk of developing DKA? 13. Is an insulin pump wearer have a higher risk of developing DKA?

A. Insulin pumps only deliver rapid‐acting insulin, blood glucose can rise quickly if insulin flow A. Insulin pumps only deliver rapid‐acting insulin, blood glucose can rise quickly if insulin flow is interrupted is interrupted B. The reduced amount of long acting insulin such as Lantus or Humalog can cause blood B. The reduced amount of long acting insulin such as Lantus or Humalog can cause blood glucose fluctuations glucose fluctuations

Necessary Visits and Protocols:

WHAT ARE THE ADVANTAGES OF INSULIN PUMP THERAPY? The best diabetes control on pump therapy is seen when the right amount of preparation and follow up is provided. For this reason there will be a commitment to be seen frequently for  FLEXIBILITY. As there is no long-acting insulin, the need to eat at specific times is education and follow up. You will need to be able to attend six (6) to eight (8) visits in the no longer essential. The carbohydrate bolus is given at the time of a meal or snack. Tacoma office over a time span of two to six month. The following section will describe what  MORE PRECISE INSULIN DOSES. The dose of insulin is matched more closely to each of these visits will entail. your insulin needs. The pump has multiple daily doses that better match your daily insulin needs. Visit 1: Pre pump Appointment with a diabetes educator where the following will be covered:  MAINTAIN BETTER CONTROL. Blood glucose testing and remembering to bolus o What is a pump? faithfully must continue. Corrective action will still need to be taken (change in o How does it work? o basal/bolus) according to blood glucose test results. It is easier to manage the What should you expect with a pump? o Begin collecting 3 months of blood glucose results dawn phenomenon (high morning glucose), growth spurts, sleeping in, overnight o Receive information packets on each product lows, illness, sports/activity, and dealing with picky eaters. o Assessment of pump readiness which will include a assessment/quiz  OVERALL. The pump may or may not improve the diabetes control and minimize o Hands on time with pumps and sensors the wide swings in blood glucose. Many children/adolescents learn to program and Visit 2: Saline trial with vendor maintain their own pumps with the assistance of parents.  This is an appointment with the pump company vendor to try out wearing the pump with saline. The following will be reviewed at the saline trail: WHAT ARE THE POTENTIAL DISADVANTAGES OF INSULIN PUMP THERAPY? o Basic review of pump features o Basic pump button pushing o  Risk of DIABETIC KETOACIDOSIS (DKA). This happens because the pump uses Saline trial set and insertion o Ordering pump and scheduling for pump start rapid-acting insulin, and there are no deposits of long-acting insulin that can act as a Visit 3: Pump Start buffer if a dose is forgotten or insulin delivery fails. Any interruption in insulin o This appointment is a one on one appointment with a diabetes educator lasting delivery will cause a rise in blood glucose. 2‐2.5 hours. Where you will get start using your insulin pump in place of  Ongoing COMMITMENT to the daily management and blood glucose testing. There injections. will be even more frequent checking of blood glucose to assist in determining the o All significant caregivers must be present best basal and bolus amounts of insulin to meet Food and activity needs. Visit 4: 3‐day follow up with diabetes educator where the following will occur:  CONTROL MAY WORSEN RATHER THAN IMPROVE, particularly when care is o Assess for low blood glucose levels transferred to the child/adolescent with less oversight. A very common problem is o Assist with first pump site change o that boluses are often forgotten. Set up home Pump Download account o Sign up for MyChart to assist with communications with the clinic  BODY IMAGE CONCERNS. Some children do not like the idea of having a pump Visit 5: 2 week follow up with Endocrine Provider attached to them as a constant reminder of their diabetes. o Review pump download and make adjustments  RISK OF INFECTION at the insertion site. This can be prevented with good o Assessment of how pump therapy is going technique and site rotation every 2-3 days. o Discuss readiness for starting on continuous glucose monitoring if that has  COST. The process of going on an insulin pump to include the office visits, initial been ordered pump cost, monthly supplies and continuous glucose sensor can be several Visit 6: Continuous Glucose Monitoring (CGM) start with diabetes educator (usually 4‐6 weeks thousand dollars, depending on your insurance. after pump start)

THE PUMP CANNOT WORK ON ITS OWN – IT NEEDS A GOOD OPERATOR Visit 7: Advanced Pump Class/Automation start appointment (Usually within 3‐6 months) THE PUMP CANNOT WORK ON ITS OWN – IT NEEDS A GOOD OPERATOR6 3 IS AN INSULIN PUMP FOR ME? ANSWERS TO SOME COMMON QUESTIONS

WHAT IS AN INSULIN PUMP? Getting Started  We encourage you to research pumps and continuous glucose sensors An INSULIN PUMP is a very small computer (the size of a cell phone) and can be clipped to a belt/waistband or kept in a pouch/pocket. before your pre-pumpGetting appointment. StartedBelow are the websites of the most  The pump holds a syringe (also known as a cartridge or reservoir) filled with rapid- We encouragecommon you to pumps research and pump sensorss and we continuous use in our clinicglucose. sensors before your pre-pump appointment. Below are the websites of the most acting insulin (Humalog, Novolog, or Apidra). The pump is programmed to give common pumps and sensors we use in our clinic. small amounts of insulin through an infusion set. This is a thin plastic tubing Animas: www.animas.com attached to the syringe.  The infusion set is inserted into the injection site (the stomach, arms, legs or Animas:Medtronic: www.animas.com www.medtronicdiabetes.com buttocks) and the needle is removed. Once the needle is removed, a small plastic tubing, called a cannula, stays in place under the skin. The insulin is delivered Medtronic:Omnipod: www.myomnipod.com www.medtronicdiabetes.com through this cannula. The infusion set may be inserted anywhere you currently give Omnipod:Tandem: www.tandemdiabetes.com www.myomnipod.com injections: abdomen, buttock and hip area or back of the arm. The syringe and infusion set must be changed every 2-3 days. At the same time, the insertion site Tandem:Dexcom: www.tandemdiabetes.comwww.dexcom.com must be rotated to a new site. Most pumps can easily be disconnected from the infusion set for swimming, bathing, or exercise. Dexcom: www.dexcom.com  The pump is not able to predict the insulin dose – the child/adolescent or parent needs to program the required amount of insulin to be delivered. As with injections, the dose will be determined based on the blood glucose results, amount of food eaten, and activity planned.  Education is essential for pump therapy to be successful. Many families describe starting on an insulin pump as if they were just being diagnosed with diabetes all over again.

HOW DOES THE PUMP WORK?

 The pump is designed to work like a pancreas to deliver insulin. The pancreas delivers small amounts of insulin known as BASAL or background insulin. With food intake, and times of high blood glucose, the pancreas will secrete more insulin known as a BOLUS.  The BASAL dose is pre-programmed, based on the child’s previous insulin needs. This can be as low as 0.025 units an hour in most pumps. Most children need a lower basal at night – this can be pre-programmed. Basal doses can be programmed to provide different insulin rates over a 24 hour period.  A BOLUS is given at the time of a meal or snack. The amount of the bolus is based on how many carbohydrates are eaten. This is referred to as a CARB BOLUS. A bolus is also given to treat high blood sugars. This bolus is called a CORRECTION BOLUS

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