New pump start, questions

[HelenM]

Questions for the experts:)
I've just spent 3 days in hospital learning to use my new pump. As I'm in France everything is very diadatic, in some ways very supervised... 2 consultants, 1 intern and 2 nurses for 5 people !! yet at the same time everything taught at the lowest starting level eg I'm the only one using the bolus wizard because I programed it myself before starting the course.Only one basal is suggested for the whole day. I have lots of questions.Heres some of them:

1) We were taught very strict hygiene procedures for changing sets/reservoirs. Washing hands (special procedure) everything laid out on sterile mat, swabbing vial top, and site with chlorexedine using sterile compresses. Over the top?

2) testing for ketones every morning whatever the BG, Is that really necessary?

3) I've asked this elsewere, but how many hours should I programme in for active insulin for Apidra? (paradigm 515)

4) This is one where I didn't understand the French answer.
My pump takes 180u, I use perhaps 100 in 3 days, I was told that I didn't need to fill the reservoir but (I think) that I needed to do another rewind after inserting the reservoir to the pump.What do others do?

5)Yesterday I ate dinner, went for a walk came back and found that my BS was 154, then looking at the pump history realised that I hadn't bolused at all. I think I forgot to press Act. Afterwards my BS reduced without any correction to 66 by 11pm. I then (without asking........ not allowed in French hospitals ate a couple of biscuits and changed my basal for the night from .6 (initial set up was for .6 all day and night)down to .5. At 3am was 76 so ate some more choc . in the morning. BS 82.In the end I used 33% less insulin for the day than on MDI

Not really a question but I'm a bit confused as to how I managed to avoid a bolus and still have to cut the basal.

Sorrry too many questions. Three days of nonstop French was very difficult:( I just hope I don't get very confused and do everything wrong.)

[morrisma]

Questions for the experts:)
I've just spent 3 days in hospital learning to use my new pump. As I'm in France everything is very diadatic, in some ways very supervised... 2 consultants, 1 intern and 2 nurses for 5 people !! yet at the same time everything taught at the lowest starting level eg I'm the only one using the bolus wizard because I programed it myself before starting the course.Only one basal is suggested for the whole day. I have lots of questions.Heres some of them:

1) We were taught very strict hygiene procedures for changing sets/reservoirs. Washing hands (special procedure) everything laid out on sterile mat, swabbing vial top, and site with chlorexedine using sterile compresses. Over the top?

2) testing for ketones every morning whatever the BG, Is that really necessary?

3) I've asked this elsewere, but how many hours should I programme in for active insulin for Apidra? (paradigm 515)

4) This is one where I didn't understand the French answer.
My pump takes 180u, I use perhaps 100 in 3 days, I was told that I didn't need to fill the reservoir but (I think) that I needed to do another rewind after inserting the reservoir to the pump.What do others do?

5)Yesterday I ate dinner, went for a walk came back and found that my BS was 154, then looking at the pump history realised that I hadn't bolused at all. I think I forgot to press Act. Afterwards my BS reduced without any correction to 66 by 11pm. I then (without asking........ not allowed in French hospitals ate a couple of biscuits and changed my basal for the night from .6 (initial set up was for .6 all day and night)down to .5. At 3am was 76 so ate some more choc . in the morning. BS 82.In the end I used 33% less insulin for the day than on MDI

Not really a question but I'm a bit confused as to how I managed to avoid a bolus and still have to cut the basal.

Sorrry too many questions. Three days of nonstop French was very difficult:( I just hope I don't get very confused and do everything wrong.)

1.) Over the top. Normal cleanliness is sufficient. (Keep the dog away from things while you are changing sites.)

2.) Not necessary unless over 250 or 300.

3.) Not sure what you are asking about. If you mean how long before eating should you bolus, the answer is 15 minutes. Your pump has Normal, Square, and Dual modes. If there is a lot of fat in your meal, use Square or dual mode to spread out the fast acting insulin's effect. Just how long to spread out is dependent on you, what you eat and how much. You will need to test frequently until you understand how your body works with the food and the pump.

4.) The recommendation is put in only as much insulin as you will use in 3 days because minimed recommends changing sites every 3 days. Many of us go 3.5 or 4 days with no problem but until you are more comfortable with the process, I'd stick to what you will use (basal & bolus) plus 30 or 40 units for priming & buffer. That way you will not waste too much insulin. As for rewind, you must rewind the plunger every time you put in a new reservoir and then prime it.

5.) Sounds like your basal rate is too high. Basal testing is very important and involves a lot of testing while fasting.

Great thing that pump but it takes work to set it up.

[Gary_W]

Hi Helen,

Congratulations on getting your pump :)

A slightly quirky answer for you here as I am not pumping yet and when I do it will be with an Animas, so please feel free to ignore my ramblings... With that disclaimer out of the way, here goes.

Q 3 is an interesting one; I took it as meaning 'how long is Apidra active for' so you can put that figure in the pump so as the IoB feature works properly?

I've been doing experiments on the Animas 2020 to establish this. In me, Apirdra SEEMS to last for around 4 hours, and I believe that :) 35% goes in hour 1, 35% hour 2 then around 20% hour 3 and the last little 10 percent goes in the final hour.

Some pumps out there use a flat algorithm for IoB so if you set a 4 hour duration, it will tell you that at hour 2, you have 50% of your bolus left. For Apidra, this calculation is about as much use as a chocolate fireguard IMO. Fortunately, the 2020 doesn't do it like that. Set on an insulin duration of 3.5 hours, it matches most of 'my' profile about right (certainly at the part of the curve where I'd do a correction anyway).

The only thing I can suggest is to set it at 4 hours initially and experiment. Take a meal bolus and set an alarm for 1 hour. At each hour, note down the amount of IoB the pump claims you still have. If you think the pump agrees with you, great. If not, try 3.5 hours or 4.5 and do it again :)

If you set the IoB to a shorter timescale, correction shots will be harsher as it will assume you have less insulin on the go already. The reverse is obviously true.

Good luck with this. I'm glad I've had my pump to play with for a while prior to getting hooked up; I pretty much know the thing backwards now and can concentrate on the plumbing / getting the basals set correctly.

Oh, and regarding your basal / bolus reduction; everyone tells me that I will need considerably less insulin when pumping. How much less seems to vary between 10% and 35%. Once I'm plumbed in, I'll let you know how much mine goes down by (if any).

Gary

[xMenace]

1) We were taught very strict hygiene procedures for changing sets/reservoirs. Washing hands (special procedure) everything laid out on sterile mat, swabbing vial top, and site with chlorexedine using sterile compresses. Over the top?
[/QUOTE]
Anal. Way over the top.


2) testing for ketones every morning whatever the BG, Is that really necessary?

No. I haven't tested for them in 30 some years.


3) I've asked this elsewere, but how many hours should I programme in for active insulin for Apidra? (paradigm 515)


42?


4) This is one where I didn't understand the French answer.
My pump takes 180u, I use perhaps 100 in 3 days, I was told that I didn't need to fill the reservoir but (I think) that I needed to do another rewind after inserting the reservoir to the pump.What do others do?


I rewind once. Stick in a new res and prime.

If I change only the set, I don't rewind or change the tubing.


5)Yesterday I ate dinner, went for a walk came back and found that my BS was 154, then looking at the pump history realised that I hadn't bolused at all. I think I forgot to press Act. Afterwards my BS reduced without any correction to 66 by 11pm. I then (without asking........ not allowed in French hospitals ate a couple of biscuits and changed my basal for the night from .6 (initial set up was for .6 all day and night)down to .5. At 3am was 76 so ate some more choc . in the morning. BS 82.In the end I used 33% less insulin for the day than on MDI


Cool. Your basals appear very high. Do basal testing asap.



Not really a question but I'm a bit confused as to how I managed to avoid a bolus and still have to cut the basal.



As I said. Learn to basal test! Then learn to set bolus rates.

Watch your BGs closely until YOU are happy they are stable.

[HelenM]

Thankyou everyone.
I thought that they were over the top with the hygiene, but I now know how to wash my hands in 6 stages, not forgetting that I need to use a clean paper towel to turn off the tap. I'm not sure how that will work on holiday, in a tent in the middle of nowhere.

I realised it was about basals, switched it down to .45 overnight and stayed in the 80s, so that seems Ok for now.
(I realised just how much more background knowledge I had than anyone else on the course. Mostly from reading on here and from John Walshes book. Sadly I couldn't recommend the site or the book to anyone since none of them read English. )
I was a good girl and tested for Ketones to show willing but I think I might as well have put the strip in water for all the change it made!
42?
I've changed the active insulin time to 4 hours. To be honest I'm not really certain how it works but the pump needs a number......... obviously the Ultimate question :)

Another day beckons, now to find what basal rate I need for to get my new prescription filled and an hour in the supermarket!

[morrisma]

Helen,
You are well on your way. Good luck and keep us posted.

[milfordj]

I, too, was taught by my diabetes educator to wash my hands carefully, not touch anything after washing, use two different alcohol swabs -- one for insulin bottle and one for infusion set site, etc. Soon as I finished my "education", having given myself injections for almost 50 years and knowing that lots of people were injecting themselves through their clothing, I returned to my "Normal" procedure of just wiping the insulin bottle top and injection site. Regarding item 4, at least with my Animas 2020, I only Rewind once, but then after inserting the reservoir and replacing luer lock cap, I have to hit Continue so that pump can take up any slack to be ready to Prime. Glad you have "THE BOOK", and sounds like you're doing great on the pump.

[Cyborg]

Congrats and good luck with the new pump. Great advice already given. As already mentioned, get the basal profile(s) set to a T, then move on to bolus testing. Don't be afraid to change settings, but take small increments over a couple days to see the affect. The book you have is a great resource, here (http://www.insulin-pumpers.org/howto.shtml) is another.

[HelenM]

I've successfully changed sites at home twice now so its getting a little less scary. I could't find my leaflet on the 6 different processes for washing hands so normal washing had to do.:)
Night time basal rate is now down to .45, (I seem to have the opposite of the dawn phenomena ) one night I had to put a 50% temp basal for 5 hours (down to .22) because I didn't want to eat lots of carbs to ensure not hypoing again. I hate having to eat or artificially raise my BS in order to feed the insulin during the night .

Hypos seem to come on much quicker, this morning I went from 98 to 45 in less than an hour . I didn't think that pushing a supermarket trolly was that energetic but I couldn't ignore it and had to leave my poor OH to finish the shopping. I have found that I have to use lower rate for even quite gentle exercise. The upside if this is that I have managed to run 3 miles without needing to grab the dextrose after 20 minutes by using a 20% temp basal. Tomorrow I'm going to try 10km.



My TDD seems to be settling at about 26 units compared with an average of 32 on MDI.


Thankyou for that link Cyborg. It looks very useful

[Coppernob]

3) I've asked this elsewere, but how many hours should I programme in for active insulin for Apidra? (paradigm 515)

Helen - welcome to the world of the pump! :cool:
I use Apidra in a Paradigm 522 (before I had a 515) - I have it programmed for 4 hours of active insulin time - this works well for me.

Good luck - I know that you will do fine as you are already making decisions and tweaking settings. Enjoy your new-found freedom. :)

[Mich]

Hi Helen,

Sounds like you are getting the hang of it. I've agreed with everything everyone says.

Here's how I deal with hygiene procedures when traveling: In my clear soft plastic cosmetic bag, I keep everything I need. I add extra batteries, my backup meter & extra strips and a package of anti-bacterial wipes. I also have alcohol wipes for the top of the insulin bottle or anything that I suspect.

In the bag I also carry several folded clean paper towels in a zip-lock to serve as my "sterile field." They come in handy wherever I am and keep things from my kit clean. I've changed in many places, including a tent while camping, at the beach (after my tubing was ambushed by the ice box handle) and in hotel rooms while traveling. After the set change, I fold up the trash into the paper towel and throw it away.

I keep the removed set pad and sharps with me in a small clear soft plastic makeup bag. I keep a pair of blunt kids' scissors in it to clip off the end of my tubing with the needle. I put these in my big sharps container (a bleach bottle) when I get home.

I wipe the site with an IV prep pad (helps the infusion set stick) and also use it to wipe the old site when the old set is removed. It seems to help seal the old site.

I've been through airport security many times with my supplies in the clear plastic cosmetic bags and alway get favorable comments. It removes the need for my things to be handled by anyone but me.

OK, so I am picky. And over the top. :T Works for me.

Mich

[RobiJo]

I've changed the active insulin time to 4 hours. To be honest I'm not really certain how it works but the pump needs a number......... obviously the Ultimate question :)



Helen - welcome to the world of the pump! :cool:
I use Apidra in a Paradigm 522 (before I had a 515) - I have it programmed for 4 hours of active insulin time - this works well for me.



The active insulin is a preventive way to keep from "stacking" boluses. For example after a meal your bg is out of your target range and you go to correct it. The pump will subtract some insulin from the correction amount based on how long its been since your meal bolus. If you "stack" or overlap the full correction bolus on top of the meal bolus you are at risk for a hypo. For me I use 2 hours, but it sounds like 4 hours is working for you. I'd leave it there for now and do the basal testing, then bolus testing.

I'm not surprised they started you at one flat basal rate, I think that's fairly typical--and is usually a good starting point. You can then adjust up/down as needed while you basal test.
Good Luck!

[RobiJo]

I've changed the active insulin time to 4 hours. To be honest I'm not really certain how it works but the pump needs a number......... obviously the Ultimate question :)



Helen - welcome to the world of the pump! :cool:
I use Apidra in a Paradigm 522 (before I had a 515) - I have it programmed for 4 hours of active insulin time - this works well for me.



The active insulin is a preventive way to keep from "stacking" boluses. For example after a meal your bg is out of your target range and you go to correct it. The pump will subtract some insulin from the correction amount based on how long its been since your meal bolus. If you "stack" or overlap the full correction bolus on top of the meal bolus you are at risk for a hypo. Its called active insulin for the amount of time after a bolus your insulin is active and working. For me I use 2 hours, but it sounds like 4 hours is working for you. I'd leave it there for now and do the basal testing, then bolus testing.

I'm not surprised they started you at one flat basal rate, I think that's fairly typical--and is usually a good starting point. You can then adjust up/down as needed while you basal test.
Good Luck!

[HollyB]

Their hygiene procedure is pretty over the top but IMO you do need to be more careful about cleanliness than for a regular injection, because the cannula is going to be hanging around in your body for a few days and it's not fun if it does get infected. So it makes sense to at least wash your hands, try not to put the business end of the set on anything dirty, and not blow on your site to dry it off if you swab your skin with Skin Tac or anything (caught myself doing that a few times!).

Checking for ketones with a normal BG just seems plain silly.

Glad things are falling into place for you.