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Bolus Not Working - multiple pod changes

Discussion in 'Parents of Children with Type 1' started by IBelieve, Dec 5, 2011.

  1. IBelieve

    IBelieve Approved members

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    Had a harrowing weekend with (omni)POD changes for 9yr old DD.

    Initially changed POD on Sat at 7pm. BG went up to 275-300 and did not correct with bolus. Gave bolus through syringe at midnight and it brought down her BG. That proved the Insulin had not gone bad. Looked through the pod window and canula looks ok; the window had some dew. There were no PDM errors. Removed the pod in the morning without deactivating. Canula looks ok. Bolused on the removed pod and it oozes out insulin; so pod is ok. The only alternative is bad site, right?

    The belly site seemed ok. The nearest skin marks from previous insertions were at least 1cm away.

    Started preparing another pod. It did not beep twice after injecting insulin. Extracted the insuling out of it and trasferred it to yet another pod. 3rd pod activated at 2.30pm. Starting BG 202. She ate 40 carbs and took 3.25U bolus; an hour later BG was 189. I was relieved, but at 6.30pm she was back at 267. Corrected with 1.65 units but no change in BG 40 mins later.

    Called after hours endo and they asked to switch to syringe. I struck her nerve when admistering and she cried a lot. Then I took off the third pod (also without deactivating) and tried a bolus on the pod. Insulin oozed out again. Good pod; yet another bad site??

    What luck! Or is there something else that may be going on?


    Thanks for your ideas/suggestions.
     
  2. swellman

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    I'm totally confused as to why you changed the pod in the morning.

    We often get a rise after changing pods. It usually takes a couple of corrections but it's all good after that. I can't imagine a situation where I would switch to syringe after only one correction bolus after changing pods for a couple of reasons. One being I can't count the number of times that a meal at 7 PM resulted in multiple corrections. The other being a pod change often results in 1 or 2 corrections afterwards. Granted, one might be meal issues ...

    Edit: So, to be clear, in our experience sometimes pod changes results in elevated Bgs. It happens and you have to be prepared and deal with it. Afterwards it's all good. I have no idea if other pumps have similar issues.
     
  3. IBelieve

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    I changed the pod in the afternoon (not morning) after the previous night's and morning corrections had failed. Our endo has recommended a pod change if we experience two consecutive failed corrections.

    I see. How much rise you get? We have never had high BG (200+) just due to a pod change in the 3-4 months we have been on a pod. And any high readings have been easily corrected by a bolus. I did not want her to sleep through the night at 200+
     
  4. swellman

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    Sorry, I guess I misinterpreted the above.

    In any event, and perhaps others will chime in here, but if we removed a pod every time we had to do 2 or more corrections to get the BG down below 200 we would be changing pods, maybe, every day - at least every other. More times than not, if we have a BG at target (100) at bedtime we will see a rise during the night - I'm guessing due to diet. I don't see that as a correction failure but more a post-meal difficulty. We treat fairly aggressively but during the evening we do an extended bolus to avoid lows at bedtime and correct any high BGs between 10 and 1ish. If we did a full correction at meal time (around 6:30 to 7:00) we would almost certainly see a low just before bed (around 9:00) and have to treat the low then fight the resulting highs well into the morning.

    We don't always see a pod change high but we see them enough and over 200 isn't unusual. I could attribute it often to an interruption of an extended bolus after a meal. We often do an extended bolus and then change the pod during. We make up the lost extended with a temp basal but it's entirely possible that the 15 minutes of lost extended could allow the BG to rise above 200. It often takes an additional correction or two, usually within an hour of each other as we rely in IOB, to get the BG back down.
     
  5. Melissata

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    For us, 40 minutes is not nearly enough time for a bolus to work on a high bg. Especially without a CGM, you have no way of knowing which direction the bg is headed when you give the bolus. I would suggest trying to be a bit more patient with the pods and highs because if you give a shot, you have no way of knowing whether you could have brought it down with the pod. Maybe stomach sites are not the best for you, I would try a different location next.
     
  6. manda81

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    We have found that when we do a pod change, setting a +50% temp basal for 2 hours, and bolusing for .50u makes us avoid that new-pod spike.

    Other than that your numbers don't look all that bad, especially with all the pod changes, and if she got upset, that alone could have spiked her numbers.

    I also agree that 40 mins, for us, would not be enough time to wait on a correction necessarily. If I am concerned, I check around the 2 hour mark after a correction, then we usually have an idea of what we are dealing with, and either correct (1/2 of suggested) again or are satisfied with the way the numbers are headed.
     
  7. emm142

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    If I changed my site every time a correction wasn't effective on the second time I'd often be changing the site twice a day. It sounds like it wasn't a pod problem but something else causing BG to he higher.
     
  8. virgo39

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    When we started on the pump, we often saw post-pod change highs.

    I found them confusing because I would check 2 hours later (usually before dinner), DD would be in range, then we'd have a crazy high after dinner and through the night. I have come to suspect that the 2-hour number was kind of meaningless -- it reflected what was happening up to the pod change and didn't show what I think was some interruption in basal/bolus delivery (whether due to the canula, site, etc., I have no idea).

    We now change her pod after dinner and do a "priming" bolus of 1.0 units (when we started this DD's ISF was 1:200!), giving from .50-.75 up front and the rest extended over 1/2 to 1 hours (depending on DD's activity and other things.

    We also are not likely to see much of a change in high BG within 40 minutes --especially given the greater range of error on the meter.

    We still see post-pod change highs sometimes, but this approach seems to work for us.
     
  9. saxmaniac

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    We had to adjust to basal very aggressively on the pod. Still do.

    If the BG goes down, and then back up after a correction, then you need more basal.
     
  10. IBelieve

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    Thanks all for your sharing your thoughts.

    It seems most people see highs after a pod change; we had not untill now, having used them for about 3 months. Also most people feel that 40-60mins is too early to see BG going down after a correction bolus. I would agree with that if one had "carbs on board". But I would expect a pre-breakfast correction to show some results in 40 mins.

    It also appears that many have to correct more than twice after a pod change. Again this is something we did not have to do in the past. Going forward, we will change pods earlier in the day so that we can correct and confirm that everyting is working during the day. It is hard on a child to wake up multiple times a night for BG readings.

    It seems like three things could fail: pod, site, or insulin. We had 15-day old Humalog fail just two weeks ago and she spent the night in 400s which made me edgy this time. I may have jumped the gun on the second pod change.

    As a reference when we use a syringe for correction, we always start seeing results in about 40 mins. About 30% of fast acting insulin is in effect 1 hour after bolus.
     
  11. Style mom

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    The direction in which BG is headed can mask the effect of a correction, especially when you test as early as 40 minutes after giving it. If BG is still heading up, the effect of the correction will not be as obvious. We always wait at least an hour to judge the effectiveness of a correction.
     
  12. caspi

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    We almost always see highs after a pod change. I try to change it around meal time and give the meal bolus right after changing it. I just started doing a temp basal as well.

    We have found that certain areas on my son work better than others. We had a hard time with absorption in the belly. I don't know if that is because he used his belly exclusively when he was on MDI. The legs seem to work best for us. But YDMV. :cwds:

    As to night time checks and waking up, that's something I am sure your daughter will eventually start sleeping through. I can test my son and he can drink a juice box and never wakes up. ;)
     
  13. swellman

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    Agreed it may plateau and stabilize, or plateau and then rise again or even plateau and fall. We usually check an hour afterwards and stack if necessary. I think our insulin duration is set to 2.5 hours.
     
  14. caspi

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    Ours is set for 2.5 as well.
     
  15. Darryl

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    We've been using the pod almost 5 years, and have had many times where BG goes high after a pod change. We've had just as many times BG goes low after a pod change, and just as many times that the BG stays flat after a pod change. It's tempting to blame a sudden change in BG on something that happened around that time, or on bad insulin, or a bad site, but in almost every case the reason for the sudden change in BG has nothing to do with the fact that you changed a pod around that time.

    Nothing magical happens when a pod is installed; the cannula goes under the skin and insulin is delivered on the same basal rate as the old pod. As long as you don't wait a long time inbetween the pod changes causing missed basal, and as along as the cannula appears properly inserted through the window, you can pretty well assume that the pod is good, the site is good, and the insulin is good. Sometimes you just need to correct for the randomness.
     
  16. Darryl

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    Most commonly, the site goes bad. You can usually see some evidence of this: redness, swelling, adhesive ripped and cannula dislodged, or insulin leaking out. The pod is rarely bad (never, actually, unless you get an alarm). We've never encountered bad insulin, ever, although in the early days we thought so. Some nights may be in the 400's because on some night, basal needs may be double, triple, or more from the "usual" basal rate due to growth hormone phases or even mild illness.

    As you said, syringe or pen needle corrections tend to be faster than the pump. We've been using them more often recently to get stubborn highs down rather than depending on the pump which does act a little slower. It depends also where you give the shot or place the pump. The stomach is usually faster than the arm or leg, for example.
     
  17. Ali

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    Per Darryls post
    I am not sure he is wrong but not sure he is right:cwds: If tissue absorbs insulin differently depending on the amount of medication injected or the age of a site used for injection then I think there can be a difference in action. When you give shots you are almost always giving more than what a basal rate might be for many of us on pumps. My basal is as low as .35 units per hour. I do notice a difference But is it due to my prior site being less effective so I am seeing the residual effect of a bad site after starting a new site or is it an absorption issue and therefore dependent on how soon after putting in a new site I am giving myself a meal or correction bolus that floods the site with insulin. :cwds::) I just do not know. Ali
     
  18. virgo39

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    Darryl,
    I would agree that nothing magical happens at a pod change, but we consistently, regardless of time of day, had high BGs after the change, even if DD was low or in range at the time of the pod change. And we find that by bolusing 1.0 unit at the time of the pod change, we've virtually eliminated them. Our DD's ISF is 1:165 (and was 1:200 when we started doing this) -- we just don't have any other explanation for this.

    In fact, in our pump download software, I flag those boluses as "priming" boluses (though I'm not sure that's really accurate) and tend to subtract them from DD's TDD when I am using TDD in other calculations.

    And our pod changes are fast -- maybe 4 minutes (we fill the new pod before deactivating the old one). But before we started doing the bolus, I used to consistently bolus for any missed basal, which was almost always .05 unit.

    We've never had bad insulin, bad site (we've had site issues later after an injury, etc.), or a bad insertion. We are also finding that corrections by syringe for persistent high BG (which for us always seem to be at night) seem to work better. In any case, we no longer follow the instructions we were given at pump start about changing to a new site after two unexplained high BGs.

    It is puzzling though. While I think it could be some other factor at play, it seems too predictable for us for me to think it is random.
     
  19. Darryl

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    Wow.... 1u is a lot! Could there possibly be a reaction to the pain of insertion that's causing the high?
     
  20. virgo39

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    It took us a while to get to the 1 unit -- it was scary. I started by hounding Omnipod for the info on how the basal is delivered (in .05 u divided over the hour, starting from the end of the hour, so a .05 u per hour is delivered at the 59 or 60 minute mark) and bolusing only for the basal we missed -- which is at most .05 u, then slowly increased it from there.

    I'm not sure the post-BG high is from the pain as such, for the most part she doesn't seem to find the insertions that painful, but her body could be responding to the "trauma" of it. Not really sure, just glad that we found an approach that seems to be helping.
     

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