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Pumping with a twist

Discussion in 'Parents of Children with Type 1' started by jenm999, Aug 23, 2014.

  1. jenm999

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    It's been a crazy week in the jenm household!

    We switched endocrinologists a few weeks ago because our team was having scheduling problems and wanted us to wait until winter to start pumping. First appointment was 8/14 (and, thankfully, we really clicked with the new doc)... we returned on 8/20 for a saline start on the t:slim and left pumping insulin!

    But for boluses only. Our son was taking only .5 units Lantus during his honeymoon, which is too little for the t:slim (.1 unit per hour minimum basal rate). So he is staying on Lantus for the time being. Since the big risk with pumping is DKA, and DKA with Lantus is less likely, they let us go straight to insulin.

    (By the way, I was wondering why the t:slim - a cutting-edge pump, would have this limitation. I found out from customer service that the t:slim pumps basal every five minutes vs. every 15 or 30 for the Ping or Medtronic. Which means a more consistent trickle but a larger hourly minimum).

    But I think this will be a very short-lived transition - once his Lantus is at 2.5 he can begin using the pump for basal as well (our endo prefers to start basals at 1/24th of Lantus dose rather than a % of TDD). He had started coming out of honeymoon a few weeks ago - instead of a steady drop throughout the night with what we presume was endogenous insulin, and relatively stable BG readings between meals, he now spikes to 300+ about three hours after every dose. We have also had to change correction factor from 110 to 80 and carb factor from 45 to 25 (in 5g increments).

    Our new team recognized this and upped his Lantus to 1.0 the morning following the 8/20 appointment but it's not helping and the poor Dexcom is barely able to keep up. So we upped it to 1.5 this morning. I'll try that for two days before going to 2.0.

    Meanwhile our son LOVES the pump. He did his first bolus in the hospital cafeteria about 10 minutes after our appointment while I was paying shouting WAIT FOR ME! I was worried about him sleeping with it and he just puts it under his pillow like all you wise people said he would, my $70 in various pouches and pockets be damned.

    More work for me, but such an improvement in his life. I am thrilled!
     
  2. sszyszkiewicz

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    Good luck JenM999 ! Sounds like a good start.
     
  3. Sarah Maddie's Mom

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    Glad your son likes it and that you've found a better fit with your new Dr.

    Just worth pointing out that that whole, "pumping = DKA" risk thing is very outdated. You'd have to be really, really checked out to miss a bg rise due to "pump failure" that was great enough and went on long enough to result in DKA :wink: and especially with a G4. I'd put the DKA risk at .001%
     
  4. Jacob'sDad

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    I'm kind of an "if it ain't broke, don't fix it" kind of guy, so I wouldn't necessarily stop using Lantus if it was working for his basal. There are many pump users who do not use the pump for basal at all and there are some that use a minimal amount of basal from the pump just to keep the insulin flowing and then also use Lantus for the balance of the basal. I have considered trying that with Jacob, but have never pulled the trigger and actually tried it.

    There are several advantages of the so called "untethered" method.
    1) The pump can be removed without losing basal because it has been given with Lantus
    2) If a site fails the basal is still being delivered by the Lantus
    3) The basal is not being delivered from the same site as the boluses
    4) Some find that Lantus just works really well for basal, especially overnight
    5) If there is a complete pump failure you are already using Lantus for the basal

    Of course there are just as many good reasons to use the pump for basal.
     
  5. Sarah Maddie's Mom

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    In seven years on CWD and twelve with D I can count on one hand the people I've met who routinely pump but inject basal insulin. Pumping with no ability to vary basal throughout the day? No ability to temp rate basal? No ability to stop basal all together to compensate for an over bolused meal? Seems to me to defeat much of the point of pumping in the first place.
     
  6. MomofSweetOne

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    I totally agree with the above. Losing the daily Lantus is one of the very bright positives in pumping in our household. My daughter has ZERO interest in untethered because of how it burns. Me for the reasons above. At 2 a.m. this morning, her correction dose wasn't working, but a 10% basal increase at the push of a button corrected that issue. She was at target at wake-up. The nights a decrease is needed temp basals are even nicer.

    Editted to add: I know of a case of DKA with pumping. Bad site, no night check, no CGM. 675 wake-up with ketones. The CGM is the safety measure IMO.
     
  7. sszyszkiewicz

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    When we switch over to the pump I imagined we would have some percentage of his basal delivered via Lantus. Its a diversification thing. Speaking of Lantus......its that time of day.
     
  8. Sarah Maddie's Mom

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    "diversification thing"?
     
  9. Sarah Maddie's Mom

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    Don't think I've ever seen a meter that went that high… but it's just worth pointing out to the OP that ketones is not the same thing as being in DKA. Not by a long shot.
     
  10. MomofSweetOne

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    But with numbers and ketones that high throughout the length of night, DKA can follow too quickly.
     
  11. Sarah Maddie's Mom

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    Like I said, I've never had a meter that could read a 675 but I have had a kid wake up with a Hi and we gave insulin and water and didn't even seriously consider that it was a situation that we couldn't manage to control within a few hours but I suppose every kid is different.
     
  12. mamattorney

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    I think it's great that you took the plunge and chose the pump that will work best for your child in the long run even though he can't pump his basal insulin right now. I'll bet you are correct and that it won't be too long before his basals are 2.5 units a day, but for now, I hope he enjoys just pushing buttons for that second helping at dinner!
     
  13. sszyszkiewicz

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    Yep.

    It seems so much of what we do is tap down the spikes and shore up the lows. Having an alternate way to get some portion of your basal without having to fret over a disconnect for whatever reason (on purpose, or by accident) seems like a valid strategy to keep the spikes tapped down. So yeah, its a diversification thing. It is a hedge against spikes. So I read somewhere that some people get 50% of their basal from Lantus and 50% from the pump. You get the hedge and the control. It is a valid strategy.
     
  14. Ali

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    One way to utilize an injection of basal is to use the smallest amount of basal you might use in any one hour on the pump be the amount you deliver as a daily dose. When I considered using a shot on top of the pump to help reduce bad sites and variances in absorption, we looked at the smallest basal amount I took over the 24 hours and used that with a reduction even to that amount, so at the time we looked, my lowest amount was at midnight and was .35 units per hour. So we reduced that to .25 applied that to 24 hours and then reduced my pump and injected that small amount. You still can use temporary basal rates but it has some protection for a no delivery of insulin, which does happen to me on occasion and also can help smooth out absorption issues for some people. I still have not bothered to do it, but it is not a bad idea for many T1s.:smile:ali
     
  15. mwstock

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    When we considered the pump, the clinic at the time recommended the Animas Ping or the Medtronic pump. It looks like both offer a .025 basal rate per hour which would equal .6 units in a 24 hour period. That is a bummer that the t-slim does not offer the low basal rate. One of the main benefits of the pump is the ability to adjust or stop basal insulin during different periods of the day or night. I set a 50% temp basal today for a long bike ride today for my son and finally set a 0% basal to pull up the blood sugar after two rounds of glucose. We road like 8-10 miles this morning. I agree with the others that with frequent blood tests you should not have to worry about DKA. We will normally change the pump site if my son is not responding to corrections and if he is running high most of the day. My son has been on Medtronic pumps for the last two years and did shots the first three.
    http://www.diabetesforecast.org/2014/Jan/images/jan14_insulin_pump_chart_3.pdf
     
    Last edited: Aug 24, 2014
  16. Joa

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    The Spirit Combo is normally dosing from 0,05 upward in steps of 0,01U. The 0,05 are given in 20 impulses every 3 Minutes because the motor is stepping in 0,0025U range.
    With a trick (using the temporarily basal rate by %) you can slow (theoretically) the Spirit down to give a basal down to 0,005U/h. This would be adminstered in 2 Steps every 30 Minutes.

    Regards
    Joa
     
  17. jenm999

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    Thanks, all, for the good wishes and thoughts about basal. We intend to pump basal as soon as feasible. Our insurance covers up to 100 ketone strips a month so we test whenever he's over 250. That plus the CGM I feel good about his safety without the Lantus, and excited to take advantage of the variable and temporary basals. It's a steep learning curve but I don't mind the extra work to give him back some sense of normalcy.

    We did have a scary low last night because we did a full correction at bedtime forgetting about all the running around he had done in the late afternoon. Our pump trainer did not teach us about the quick bolus function but I think this is probably when it would have come in handy - we could have given him half the correction and checked again when we went to bed and avoided sleeping at the foot of his bed clutching the dex and a juicebox...

    Or, instead of halving the correction bolus, would you have tweaked basals?

    So much to learn!!!
     
  18. Sarah Maddie's Mom

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    I do a lot of half corrections before bed if she's been active then, if I see the numbers still going lower than I'd like, especially with IoB from the correction, then I'll drop her basal down a bit (80% for four hours seems to be my lucky combo after a hard training session :))
     
  19. sszyszkiewicz

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    Ahh yes, I call that living "dot to dot"! Currently the dots are born on the 2's and 7's. ;)
     
  20. mmgirls

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    isn't a quick bolus just giving insulin and not considering BG or IOB?

    Did you ratios and correction factors change at all when you went on the pump?

    AT that start of pumping yes I would do 1/2 corrections and see where that gets you, and you can easily give another correction via the pump in a few more hours.

    BTW my oldest get 8unit of Lantus and about 4 from the pump. My youngers gets 4units via the pump and will try to start with at least 1unit of Lantus very soon. I love the fact that my oldest have not had any significant ketones with a bad pump site, it is very comforting to know that it is in the background.
     

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