Advice on our New MiniMed CGMS Please...

[sausalater]

Hi experts out there! Thanks for all of your encouraging and informative posts! We just got our new MiniMed Guardian on Friday, put it in my 2 year old daughter on Friday afternoon and were so excited BUT...

1. It worked great over night, then the numbers started to get haywire yesterday. (Guardian said 200 and finger check said 100 causing a re-start)

2. The sensor stopped working (it fell out) yesterday evening after our bath time. (Bath on Friday evening went ok, yesterday not so well...)

So, we could really use your advice on how to keep the Guardian properly synched up and as accurate as possible. Plus, advice on how to keep it in there for longer than a day... I see some folks using them for 12 and 15 days in a row. Wow! I need some of whatever they're doing!

Other questions:
1. Any way to make the alarm louder? We didn't hear it through the baby monitory when it went off at night. We've got it set at "long"
2. Now that it's not in use while we regroup, how do we turn off the Guardian completely so we don't waste the battery? And, should we just stick the transmitter in the little charger for a few days, or will that burn out the charger?

Thanks for any advice you can give!
Andy

[binmoosa]

My daughter using the old one, and still wating for the new one , I think that you need to use it in a fatty area. :cwds:

[Rachel]

I am by no means an expert ... only on day 4 of this. So take what I say with a mountain of salt ...



So, we could really use your advice on how to keep the Guardian properly synched up and as accurate as possible.

The tip we've gotten on this - both from users here and our MM trainer - is to never calibrate when there are arrows - so, only calibrate when the bg is relatively stable.

See the recent thread on the parents forum for more info on calibrating:

http://forums.childrenwithdiabetes.com/showthread.php?t=4254

About the alarm level - We are struggling with that too. Our trainer said the loudest is the "long" setting that you are using. I am thinking of switching to the belt clip, rather than the pump pack, at least at night to see if the pack is muffling the sound. If that doesn't help I may switch to vibrate ... to see if that bugs Will enough that he would wake up and call me. This is a BIG issue for me ... I really was looking forward to being awakened by the alarm rather than sleeping through it!:rolleyes:

[EmmasMom]

Hi Andy,

I'm sorry you guys had a rough start! Much like pumping, it gets easier pretty fast! (I'm not actually sure you're pumping since you're using the guardian, but you get the idea!;))

I'm going to give you detailed info on how *we* do it. We have had really phenomenal results on my 2-year-old daughter and love this thing, but of course YRMV! Hopefully there will be something here that's helpful to you!

On sensor site change day I plan ahead so I can insert the new sensor about 2 hours before a stable blood sugar, this is often after dinner, so I can get the first calibration at bedtime, then the second one during the night when her numbers are the most stable.

I take the sensor out of the fridge 1-2 hours before it's time to use it, so it can warm up. This is an important step! If you put it in cold it will take much longer to work well, and if you open the wrapper before it's room temp condensation will affect the sensor performance. Just take it out of the fridge and let it sit unopened for at least one hour.

We use LMX4 numbing cream. I put it on 30-45 minutes prior to the insertion and cover it with a clear dressing. When it's time I remove the tegaderm and wash the cream off with soap and water, any residue will affect how well the sensor sticks, so make sure you clean thoroughly if you use any numbing cream.

To prepare the site I wipe it with alcohol, and allow it to dry. I do this 2-3 times.
I use Emma's upper butt cheek, hips and flank area for sites. I think the more padding the better because we get much better accuracy, and no false lows, when the sensor is as deep as possible. Depending on where I'm putting the sensor I tilt the needle to a minimum of a 45 degree angle, sometimes closer to 60 degree angle if I think she has enough fat there.
Once the sensor is in and the needle is out I leave it alone for 10+ minutes. If there's no bleeding,(we had bleeding a few times in the beginning, but haven't in many months now), I connect the transmitter, and then use IV Prep around the area. I'm very careful not to let the IV prep get near the sensor, only on the adhesive and around where the clear dressing will go. Then I cover the whole thing with a piece of Tegaderm. I think Tegaderm sticks much better and lasts much longer than IV3000, (the dressing they send with it). Once it's in place I never have to touch the sensor again until day 7 when I disconnect briefly, restart the sensor, use more IV Prep and a new Tegaderm.

On the first day of a new sensor the accuracy is the worst that it will be during it's life. It takes several good calibrations to get things running smoothly, which is why I like the night calibrations. The first night I can do 2-3 really good stable cals. The first one at bedtime just gets things started, then one around midnight if she's stable, and one in the early a.m.. Once I calibrate when she wakes up in the morning we've got a good stable history of calibrations and a warmed up sensor.:)

Some helpful tips on calibrating:
Do some at night if that's a stable time, it will make your days that much better.
Do one first thing in the morning, and then wait 15 minutes before breakfast. The system takes 15 minutes to update the sensor for each calibration, so if you calibrate and then immediately eat, your blood sugar will start to rise before the calibration has even updated you Guardian. This can cause trouble if you always eat immediately after calibrating.
Pick one or two stable times during the day to calibrate the system, at least 2 hours after eating or taking insulin, and at least 10-15 minutes prior to eating. Never during very active times!
Don't over calibrate! If you send every test to the Guardian as a cal you will really confuse the system with rapidly rising and falling numbers, and with the 15 minute delay on the cals it's very unwise to do them when things are changing.
My daughter's BG can spike 100 points within 15 minutes of eating, so if I cal when she sits down to eat, and the sensor updates with that premeal number 15 minutes later when her BG is actually 200 instead of 100... well you get the idea!

As far as hearing the thing... If you're using the Guardian you should be able to place it on a bedside table or clip it to the side of the bed. (I used her crib's bumper pads with the Guardian, now we just leave her pump in her bed). Then put a baby monitor near the unit. I keep my baby monitor turned up pretty loud at night so I'm always sure to hear the alarms. If I'm really sleeping soundly I may not hear it until it gets to the siren alarm, but that's only about 10 minutes, so It's usually fine. As long as the alarms are set at good levels a 10 or even 20 minute delay shouldn't be a big problem.

You may have read my other post about changing the alarm settings based on time of day and activity level. If Emma's really stable at night and running at 100 I'll lower the low alarm to 90 so it wont keep alarming, but will still alert me if she starts to drop. During the day I keep the low alarm higher because her numbers are up and down with each meal and bolus, and I want to catch any fast drops before they're a problem. Since you have prediction alarms on your new unit you may not have to change the alarms as often, (I'm jealous!), but just keep in mind that a safe low alarm during a stable time and during a rapid fall may be very different.

Well, that's all I can think of for now. Please ask questions as they arise, as I'm sure you can make this great system work for you! It takes a little patience at first, and there are new things to learn, but you will get it! I really have a feel for how to use the trend arrows and graphs now, and there are days that we only do 4 finger sticks in 24 hours. Amazing! :)

Oh I would just leave the transmitter in the charger, it wont hurt it. You should be able to turn the guardian unit off, but I haven't used the new one, so I'm not sure how... Sorry!

[WestinsMom]

Wow, Amy, that was great! I think I will print that so I have it handy when we get ours in the next couple of months! Thanks for taking the time to type all that!

[Mama2H]

Wow Amy! I can't wait to be as good as you :D You mentioned "if there is no bleeding" What do you do if there IS blood? Is there something different or just wait for all bleeding to stop before hooking the sensor up?

[EmmasMom]

Wow, Amy, that was great! I think I will print that so I have it handy when we get ours in the next couple of months! Thanks for taking the time to type all that!

No problem! I hope it helps somebody!;)

Wow Amy! I can't wait to be as good as you :D You mentioned "if there is no bleeding" What do you do if there IS blood? Is there something different or just wait for all bleeding to stop before hooking the sensor up?

Thanks!:o I don't know that I'm "good", just experienced and a bit obsessive!;)
If it bleeds you just hold a bit of pressure and make sure it stops before you connect the transmitter. We had a few that bled in the first month, and it never affected the accuracy or anything like that, but it was startling since we've never had an infusion site bleed. The longer needles are more likely to hit a capillary than the little 6mm we use with the pump.

Best of Luck!!!!!!!!!

[Andrews mom]

We get cgms tomorrow and I did print it out! We go to training on Thursday and I bet we could just go thru Amy and get better training!! Thanks for taking time to type that- it really helps us out a lot. I have a question about how some people talk about inserting it at 45, some had said 30 and others say 60... not to sound totally stupid but what is that about? I thought the inserter would be like our one for when we change the site for his pump??

[EmmasMom]

I have a question about how some people talk about inserting it at 45, some had said 30 and others say 60... not to sound totally stupid but what is that about? I thought the inserter would be like our one for when we change the site for his pump??


This inserter is different, and it holds the needle at an angle. I pasted a pic from the MM web-site so I hope you can see it. You can vary the angle of insertion depending on how you hold the inserter. If you push it more forward the needle will go deeper, if you rock it back a bit the needle will be more shallow.
If you keep it's little "feet" flat on your body the insertion will be about 45 degrees.

https://store.minimed.com/images/mmStore/product_images/MMT-7500_L.jpg

Good luck on your start!:)

[sausalater]

Wow. You're awesome, Amy!!! Thanks so much for that helpful post and the follow on's were great, too! We put the new sensor in today and we'll see how it goes! :D

Thanks again,
Andy

[kel4han]

I was going to say the same, AMY...Emmasmom......I think you should consider putting your knowledge and experience to work for all of us out there that need education and training. Hint Hint........Maybe a new career you could be passionate about???:D

[sausalater]

Any tips on how to stop the "weak signal" beeps in the middle of the night? We've already got the thing only about 3 feet away and it beeps randomly throughout the night... presumably when she rolls onto one side or another.

Thanks!
Andy

[EmmasMom]

Any tips on how to stop the "weak signal" beeps in the middle of the night? We've already got the thing only about 3 feet away and it beeps randomly throughout the night... presumably when she rolls onto one side or another.

Thanks!
Andy


Unfortunately if it's 3 feet away and her body is in between the two it may lose the signal. That stinks! I would just try moving the receiver closer to her, even in her bed if that's possible.
We don't normally have issues with losing the signal at night even if Emma rolls on top of the pump, and I'm sure it's because it's still so close to the transmitter.

Good Luck!

[EmmasMom]

I was going to say the same, AMY...Emmasmom......I think you should consider putting your knowledge and experience to work for all of us out there that need education and training. Hint Hint........Maybe a new career you could be passionate about???:D

I would love to! I'm really thinking about becoming a CDE, or at least a rep for a diabetes company, (MM should totally be paying me already!;)) I'm not ready to do that right now, since my "services" are still needed at home 24/7...:rolleyes: Someday!

[Reagan's Mama]

Ditto on the kudos Amy! :)

One question - if you are calibrating first thing in the morning and then waiting for breakfast, are you sticking her again to get a BG for the Wizard for breakfast dosing, or using the number that the sensor is giving at that time?

May be the difference in 15 minutes doesn't matter that much if she's stable?

this is definitely something that I am not doing. Currently we sit down to eat, stick, cal and then start eating. Maybe this will help us out since I cal at breakfast and lunch. Could be an explanation for some of our "off" numbers.

Thanks for your mountains of knowledge!

[amouat]

How were you able to get a continuous monitor for your 2 year old? I am interested, with a newly diagnosed 2 year old of my own...

[EmmasMom]

One question - if you are calibrating first thing in the morning and then waiting for breakfast, are you sticking her again to get a BG for the Wizard for breakfast dosing, or using the number that the sensor is giving at that time?


I use the original finger stick number for her breakfast bolus. I often give her at least part of her breakfast insulin, as well as any correction she may need when I do the finger stick so it has time to get started before she eats (10-15 minutes).
Then for the rest of the meal I bolus as she eats, and no additional blood sugar is needed for those boluses since it's just covering carbs.:)

How are things going now?

[Budapest]

Hi,

Sorry to hear that your child is also dx'ed. You would need to speak to your endo to get it prescribed. Are you using an insulin pump already? In case your dr is not willing at all, consider looking for another doc.

We have a 2.5 yr old who was diagnosed 6 mo ago. We ordered the Guardian RT for him on Friday and hope to start in a week or two.

Good luck.

[EmmasMom]

How were you able to get a continuous monitor for your 2 year old? I am interested, with a newly diagnosed 2 year old of my own...

Any pedi endo can prescribe a CGM for any child. :)
MM is FDA approved for 7 and up, and Dexcom is currently approved for 18 an up, so any CGMS use in small kids is considered "off label", but it's only because of the limited research done in this age group. Many things, including Lantus and Levemir, are not FDA approved for young kids, but are used routinely in this age group.

The best thing to do is talk with your endo about the pros and cons, do some research and see what you think! Many endo's are still not using them, mostly due to cost and lack of insurance coverage, but it's only a matter of time!

Next to her pump, the CGM is the best thing we've ever done for my daughter. It has changed our lives SOOO much! It's not always perfect, but it's a million times better than not having it! :D

[Reagan's Mama]

Doing better-we are finally over the ear infection and had our 3rd negative on the staph. Do I dare say that we are well! (for now)
I may be able to say that I like the CGM again soon!
I am using the trends much more and have changed her alarms a bit.

I think the 15 min before a meal cal is working much better.

Thanks!

[sausalater]

Thanks again everyone for all your help on our daughter's situation... We're starting to get the hang of things! Last sensor lasted 6 days and we're on day 2 of this new sensor. Overall, we're very happy with things, but still have some questions:

1. Is plus or minus 50 about right? For a 2 year old? We're seeing some times when it's right on, and other times when we're up to 60 or 70 points off... it seems to be about 20-30 off most times. It's still helpful to know the gist, but it's frustrating to be flat at 100 (as we were last night) and have her finger stick be 71.

2. How do you have your alarms set up? Predictive? We're getting alarms all the time for fall rate, predictive and such. So, if she's at 200 and starts dropping fast, we get the fall rate alarms, then we get the predictive alarm as she approaches 100 (our limit) and then we get the actual when she passes 100, which keeps going off until we get her out of 100. Similar on the high side. I like having alarms, but I guess it would be nice to just have less. We got the picture on the first alarm! LOL. And, in the middle of the night, it sucks to have to get up to turn off each of those alarms when we already know the situation. Any ideas? Any way to snooze all alarms? If we turned off the actual low/high bg alarms and only used the predictive ones, would they not alarm in any situation where we're below our target?

Thanks again for all of your help!
Andy

[jpb286]

Set the "low snooze" alarm setting higher than it is currently set. This will increase the time between alarms for low BG. Do the same with the "high snooze" alarm settings.

I dont know what you mean by "predictive alarms".

The interstitial fluid does not directly corrolate with blood glucose readings. All the CGMS sensor is doing is measuring a change in electrical current that fluctuates based on the amount of glucose present. It is NOT performing an electrochemical test like your meter is; it is simply determining electrical potential (like an ammeter) and uses a computer algorithm to "come up with" a corresponding glucose value.

Its not a sure-fire method, which is why they tell you to still do fingersticks, but it is reliable enough to trend, and make reasonable predictions as to whether the glucose is rising or falling.

It lags behind blood glucose levels by about 20 minutes, so YES, a BG of 71 is acceptable for an ISF reading of 100mg/dl.

[Rachel]

The interstitial fluid does not directly corrolate with blood glucose readings. All the CGMS sensor is doing is measuring a change in electrical current that fluctuates based on the amount of glucose present. It is NOT performing an electrochemical test like your meter is; it is simply determining electrical potential (like an ammeter) and uses a computer algorithm to "come up with" a corresponding glucose value.



Thanks for this, Paul. I thought it was sucking up the glucose somehow, which, now that I think of it, makes no sense because where would it go once it was sucked up?!!

Andy, I've not heard of having a predictive or fall rate alarm. Even if we do have it on our unit (MM522) I think I might turn them off. We look at the screen so often - ahhh, our patient child - that I see the arrows and watch the trending. Too many alarms and I'd be afraid of alarm fatique.

We've gotten some 50 point differences too ... but almost always when there is some movement in the glucose level. I concentrate more on the trend arrows and graph than the actual number. But your example is a good reminder to fingerstick when on the lower end, just to be sure. I've been getting a little lax - already!

[EmmasMom]

Hey Andy,

You guys are they only ones around here with the new guardian unit, we all have the MM pumps, so they're a bit different. We don't have predictive or rate of change alarms. We just get an alarm when the low or high limit is reached.

If there's a way to turn off the rate of change alarms that might be best. Just having the high and low, with the low prediction alarm seems like plenty! Once you're dealing with tighter control those other alarms will probably be more helpful, but when kids are going up and down all day the alarms could definitely wear you out!

I have our snooze alarm set to 45 minutes on the highs, (gives her time to come back down after a correction), but sometimes if she's really high and I know it's going to take longer to get back in range I'll set it to 1:30 before the next alarm. That way you're not getting out of bed every 45 minutes.
Also if you're getting a lot of high alarms you can set them higher, and then lower them as you get better post meal numbers, (or whatever). There's no reason to drive yourself crazy with alarms while your making insulin adjustments as long as you're paying attention to the data.

On the lows I have the snooze set to 20 minutes, but I do notice that the sensor is always a bit behind when I treat a low. It will take longer to see the rise on the sensor, but as long as it's not showing a drop I know it should be coming back up. (I used to retest her because I was unsure if she was rising fast enough, but now I just give it a few extra minutes.)

I agree that the alarms can drive you nuts on occasion, but it's all a trade off. I get up just as many times every night now as I did before the sensor, (sometimes more), but when I go to bed I'm not scared! I'm very confident that if there's a problem in the night I'll know about it, and that's such a great feeling! When numbers are good I can actually sleep straight through w/o worry!:) Ahhhh

As far as the accuracy, we are usually closer than what you're getting right now. The graphs I've posted on my sensor update threads are pretty standard for us. The first 12 hours are typically the least accurate for us, and then after a few good cals it's much better, then when it's "dieing" (somewhere between day 7-10) it can get pretty wacky.
It does depend on when you're doing the tests. If things are pretty stable the numbers should always be within 20%, during a very rapid change the 15-20 minute lag time can give you very different numbers, but the trend is still there. Anytime I see two arrows on the screen I know that the number is going to be very different, but it will even out once the change slows down. The rate and direction of the graph are the most important things with roller coaster numbers.

I hope it continues to get easier and make more sense! It sounds like you guys are all doing great!:)

[sausalater]

You folks are so helpful. Thank you! Here's another question. I uploaded all the data to our carelink.minimed.com site, but how do I get all the nice icons and stuff that shows when we bolused and fed and such right on the graph? It doesn't seem to show on the carelink graph. Maybe that's only an option with the other software?

Andy

[EmmasMom]

Are you uploading info from a pump as well as the unit? When I upload the pump all the info; carbs, basal & bolus insulin, blood sugars & sensor data all go into the carelink program and can be viewed in a variety of ways. I can add activity, ketones, and few other things, but that's it.
I'm not sure how that will work with the guardian unit. Do you put your carb and insulin data into it?? (we did put some info into the old GRT we used) Otherwise the carelink program will only have your sensor info.

Here is an excel program where you can combine all the data into one place, but it's fairly labor intensive. It was created by one of the other users davisxa.
http://davisxa.googlepages.com/cgmtrackingspreadsheet

Good Luck!

[Budapest]

I uploaded all the data to our carelink.minimed.com site, but how do I get all the nice icons and stuff that shows when we bolused and fed and such right on the graph? It doesn't seem to show on the carelink graph. Maybe that's only an option with the other software?

Andy

Unfortunately it does not seem to be possible. I am really not happy about it. This is being discussed in another thread here: http://forums.childrenwithdiabetes.com/showthread.php?t=4387

[sausalater]

Thanks... The old guardian let me do it. We are entering all the carb and bolus info into the guardian. We've even been entering the *non-calibration* meter readings in the non-calibration section...

But, it just spits the data out into a big sheet and doesn't give us the pretty stuff. I haven't played around with it much, but if it would let us output the raw data in some way, I bet one of us could create a spread sheet like davisxa's above right from their raw data.

Andy

[sausalater]

No luck. I just played around with it to see if there's any kind of excel or text output, but there isn't. Bummer.

Andy

[Rachel]

Thanks... The old guardian let me do it. We are entering all the carb and bolus info into the guardian. We've even been entering the *non-calibration* meter readings in the non-calibration section...

But, it just spits the data out into a big sheet and doesn't give us the pretty stuff. I haven't played around with it much, but if it would let us output the raw data in some way, I bet one of us could create a spread sheet like davisxa's above right from their raw data.

Andy

Andy, Does this mean when using the Guardian you aren't able to access all the various "Reports" that are available on the site?

Just trying to understand .... After I upload the data, I click on the report tab and see on the left side of the screen a list of report options. When I click on Daily Summary, for example, and then select the date I want and then the Go button, it generates a report with three graphs that are lined up on top of each other ... glucose, insulin, and carbs.

Are you saying that this report (and others like it) aren't available for Guardian users?

Rachel

[sausalater]

Nope. I have the same reports you do, I think... BUT, it doesn't show the little icons on the graphs that indicate when we gave boluses and fed carbs... The old software used to do that and most of the pretty graphs I see around show it, but not this carelink site as far as I can tell... :-( At least, not yet.

Andy

[Rachel]

Got it. Thanks.

The report that I seem to be using most is the Daily Summary. I like it because the three graphs - Glucose, Insulin Delivery, and Carbs - are all lined up by hours, so I can look back and forth among them to see patterns / problems / sucesses (!). Not quite what you are looking for, but maybe the next best thing?

Does anyone use the two week reports regularly? So much changes in 2 weeks for us - cold, growth spurt, etc. - that I find it is too much info.

How about if I start a new thread for a CareLink wish list? I'll pull the info into a letter to MM.

[Budapest]

Moved the whole post to new thread http://forums.childrenwithdiabetes.com/showthread.php?p=40013&posted=1#post40013