I’ve run across conflicting information regarding how often to change my infusion set and rotating my sites. What is the recommended procedure?
Do I need to check for ketones even though I am on the pump?
What do I need to do if I want to go off the pump for brief periods of time?
I’m going to be traveling overseas and need to know what supplies to bring and what else I need to be aware of?
In the past year I’ve gotten an infection at the infusion site a couple of different times. How do I recognize an infection in the early stages and does anything help prevent them?
The adhesive I’ve been using leaves a sticky, messy film on my skin. What products would remove it?
I have been on the pump for a while and am wondering what the temporary basal rate is used for and how to use it?
1. I’ve run across conflicting information regarding how often to change my infusion set and rotating my sites. What is the recommended procedure?
The best thing to do is to discuss it with your healthcare team. However, there are some general recommendations, which you can follow.
Changing your infusion set and rotating your site is usually recommended at least every 48 hours for metal needles (Rapid or Classic) and at least every 72 hours for the Teflon® cannula sets (Ultraflex or Tender). Studies have shown that exceeding this time frame dramatically increases the risk of infection. These recommendations are discussed in the package inserts.
To prevent lipohypertrophy, the build-up of fatty tissue – which impairs insulin absorption, it is best to not use the same spot more than once a month and move at least one inch from the previous site. If you notice that it takes more and more insulin to get the same blood glucose results, this is a sign that you may have developed lipohypertrophy. You will need to avoid those areas and find new ones, but beware of low blood glucose when you start to use brand new sites. Prevention of infection and lipohypertrophy is much better than treating it. Once site problems start they can be challenging to treat.
Each person is unique in their body’s tolerance of infusion sets and the adhesive that holds them in place on your skin. Check your site at least twice a day for any signs of redness, pain, and swelling and troubleshoot unexplained high blood glucose levels. If any of these are present, it is best to change your set, even if you just changed it. Listen to these signals your body is sending. Then check with your doctor or educator to determine whether or not medical treatment is necessary. Site infections often progress quickly – so don’t delay!
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2. Do I need to check for ketones even though I am on the pump?
Yes, there are times when it is important to check for ketones, but hopefully not often. The pump uses only fast acting insulin; so if delivery is impaired (a bad site, the cannula slips out, the cartridge and tubing connection is loose) blood glucose levels can elevate quickly.
A safe guideline is to check for ketones any time your blood glucose is over 250 and you don’t know why. If ketones are positive, this means that insulin levels are very low, your body can’t use glucose and has needed to burn fat for fuel. Ketones make your blood highly acidic, which causes you to feel nauseated and vomit, and can rapidly lead to dehydration. If left untreated, this can lead to DKA (diabetic ketoacidosis), which is a medical emergency.
Signs and symptoms of DKA may include nausea and vomiting, abdominal pain, a fruity odor on your breath, shortness of breath or breathing fast. If you have any of these symptoms, you should seek medical attention immediately.
There are two ways to test for ketones at home: one is by a urine ketone test strip. Bayer Corporation makes individually foil wrapped Ketostix, which come 20 per package (to order give your pharmacist this- NDC 0193-2640-20). The nice thing about these is they can be used until their expiration date. The vials of ketone test strips expire 30 days after opening, but tend to be what most pharmacies carry.
The second way to monitor ketones at home is with the Precision Extra meter. This meter measures blood ketones as well as blood glucose. Ketones show up in the blood up to 4 hours before the urine. This can be a great advantage in preventing the progression from ketones to DKA.
More info on treating ketones and DKA prevention can be found by asking your health care team, or in the book, “Pumping Insulin” by John Walsh, which can be purchased online at Disetronic Direct.
Remember, testing for ketones using the above guidelines along with frequent blood glucose testing, can decrease the likelihood of developing DKA. If ketones are present, you should follow your healthcare professional’s instructions for taking an extra amount of fast-acting insulin by injection, not by the pump, and drink plenty of sugar-free fluids to avoid dehydration. You will need to troubleshoot the pump to look for reasons why you are not getting the insulin. The presence of ketones means insulin has not been delivered for several hours.
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3. What do I need to do if I want to go off the pump for brief periods of time?
The most important thing is to have a back-up injection plan from your healthcare team from the first day of pump therapy and the neccessary equipment to implement that back-up plan. That way you’ll know how to cover the period of time you are off the pump, whether it’s by choice or necessity (and this doesn’t usually happen during office hours!). Each person responds differently, so frequent blood glucose monitoring is an important part of this plan.
When off the pump for up to an hour: test blood glucose when you reconnect, and cover the missed basal insulin. If high, use your high BG bolus, which has been predetermined by your healthcare team.
When off the pump for a few hours: with fast-acting insulin, you will need to take an injection every 2-3 hours.
When off the pump for more than a day: you may want to use longer acting insulin such as NPH, Lente, Ultralente or Lantus. Again, check with your healthcare team for specific doses.
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4. I’m going to be traveling overseas and need to know what supplies to bring and what else I need to be aware of?
The most important thing is to pack enough supplies for the duration of your trip and then DOUBLE it. This will allow you some flexibility if plans change.
A letter from your doctor, or the handy wallet travel card from Disetronic describing the pump and supplies, can help you get through security and Customs more easily. Prescription medications, such as insulin, need to be carried in the original box labeled from the pharmacy.
Carry with you at all times an “emergency kit” consisting of a meter and test strips, pump supplies for 2-3 cartridge and infusion set changes, extra insulin (including long-acting), PowerPacks, ketone test strips, medical ID, back-up insulin delivery system (pen, syringe, second pump) and fast acting sugar for treatment of low blood glucose. It is also helpful to have a written copy of your basal profiles, insulin-to-carbohydrate ratios and your high blood glucose and/or ketone boluses, and a list of other medications you use. If you are traveling with a companion, you may want to carry a non-expired Glucagon Emergency kit. These items should be in your carry-on bag, not in checked luggage.
Once the supplies are packed, the rest is easy! Time changes are as simple as changing the time on your pump. Beyond packing and carrying supplies, living with a pump on a long trip isn’t much different than staying at home, unless you cross a time zone. Time zone changes are easy with a pump because you can precisely control the amount of insulin you use and the time when you use it. Many pump wearers find that if the time change is less than 4 hours, changing the pump clock at your destination works best. If you fly over several time zones, you may need to change your pump clock several times during the trip for a smoother transition.
When traveling, it is extra important to be aware of your blood glucose levels. An extra blood glucose test may make the difference between a good trip and a loss of BG control. Count carbohydrates for a bolus as you usually do at home. Don’t be afraid to try new foods – that’s part of the excitement of traveling! Just make the best estimate and then check your BG in a couple of hours. Be aware of your exercise and activity plans for the next few hours, and make the adjustment. Use the formula determined by your healthcare team to treat high BG levels and use a temporary basal rate, as needed.
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5. In the past year I’ve gotten an infection at the infusion site a couple of different times. How do I recognize an infection in the early stages and does anything help prevent them?
Always contact your healthcare team if you think that your infusion site has become infected. Site infections can progress and worsen quickly and may need medical treatment. Signs and symptoms of a site infection may include redness, a “hot” sensation, a hard or painful lump, and/or blood glucose levels that are consistently elevated. Site infections tend to start at the tip of the infusion set needle or catheter deep under the skin. Sites should not be painful; if you are experiencing pain, change the site immediately and check for other signs of infection.
There are multiple steps you can take to prevent a site infection:
Always wash your hands thoroughly before handling an infusion set.
Cleanse the site prior to insertion. There are several antiseptics available over-the-counter that you can use for cleansing the site. Many of these preparations also leave a tacky residue when drying and aid in infusion set adhesiveness. It is important to always let the antiseptic dry completely before inserting the infusion set. Some of the most popular preparations include Hibiclens, Skin Prep, IV Prep. You can order IV Prep online through Disetronic Direct.
Another important way to prevent a site infection is to follow the manufacturer’s recommendation for changing the infusion set and the site. A general rule is not to wear any infusion set longer than 2 (metal needle) to 3 (Teflon® cannula) days.
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6. The adhesive I’ve been using leaves a sticky, messy film on my skin. What products would remove it?
There are some products that can be used including Uni-Solve® or Remove®, which can be purchased online through Disetronic Direct or Detachol, which can be purchased through Ferndale Labs in Michigan by calling 800-621-6003. One alternative is to use a baby oil-soaked cotton ball to gently remove the infusion set dressing.
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7. I have been on the pump for a while and am wondering what the temporary basal rate is used for and how to use it?
The temporary basal rate (TBR) can be used to adjust your insulin dose when your blood glucose levels are above or below your target level. While every person is different, some things that can affect blood glucose levels and insulin requirements include illness, stress, changes in activity patterns, menstrual cycle, and medications. Be sure consult your healthcare team for their specific recommendations pertaining to your use of the temporary basal rate feature.
A TBR decrease may be used when your insulin requirements decrease. A common situation is when people exercise and they need less insulin. For example, many physicians recommend a 50% decrease during the exercise, or some suggest that you start the decrease 30 minutes before the exercise. Exercise can increase your body’s insulin sensitivity for up to 36 hours. Because of this, some people need to continue the temporary basal rate decrease for several hours after the exercise. You must monitor your blood glucose level frequently during the activity and every two hours after the exercise to determine your response to the exercise and the necessary duration of the temporary basal rate decrease.
A TBR increase may be used when your insulin requirements increase, such as during stress or illness or to counteract the glucose-raising effects of some medications. The amount of the TBR increase depends on the causes of the high blood glucose levels. Illness can increase basal insulin requirements by as much as 100%, while a woman’s menstrual cycle may increase requirements by a lower percentage. A temporary increase may be required for several days, so it’s a good idea to start increasing slowly and monitor your BG closely to see what works for you.
