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ОглавлениеChapter 4 Getting the Patient Ready
Goals and Objectives
It may seem like a simple concept to “get the patient ready” for pump therapy, but as the HCP responsible for prescribing the pump to the patient, it is also your responsibility to make sure the patient is prepared to achieve and maintain success with pump therapy.
Formal training of the patient to use a pump has three stages: prepump education, pump start-up, and pump therapy follow-up and management. Prepump education is usually spread over a few weeks, with a minimum of three visits of 1–3 h each. The usual pump start-up (see Chapter 5) consists of one 3- to 4-h session. Pump follow-up and management can range from a few weeks to several months.
When planning the prepump education, consider both the learning style of each patient as well as their general diabetes knowledge. Some pump patients complete just two to three 1-h preparation sessions with a verbal exchange of information, whereas others need a structured learning situation, such as several 1- to 3-h sessions or classes spread over 3–4 months, with written tests to gauge the information flow. The average patient will find the latter a bit much and may become so intimidated by the formality that they decide pump therapy is just not for them. A combination of individual and group sessions may work well because many patients benefit from group interaction. Success begets success, and clinicians are likely to design and implement what they have found works best for their patients.
A group class covering some of the pump education topics can also be time-efficient for the healthcare professional/team. Ideally, patients should have sessions with an endocrinologist and a CDE, who can be a registered dietitian (RD), registered nurse (RN), registered pharmacist (RPh), or exercise physiologist, and has experience with pump therapy. Consultation with a psychologist, who specializes in diabetes and understands pump therapy is also extremely useful.
Another consideration for pump readiness is to recommend that your potential pump patient attend a local pump support group. Most pump support groups are facilitated by a pump-savvy CDE who can manage the tone of the overall group and keep the focus on the topic(s) being discussed. The caveat to attending a pump support group is that, depending on the patients who are present, potential pump patients may become inappropriately excited hearing how “easy” pump therapy is. On the other hand, potential patients may become so dismayed by complaints that they decide pump therapy isn’t for them. In both cases, pump therapy reality lies somewhere between the supportive successful pump patient and the unhappy struggling pump patient. Many clinicians recommend potential pumpers attend at least two support group meetings before making the final decision to choose pump therapy.
There are education components that will guarantee successful pump therapy. Although the patient’s education begins as you present the “Steps for Helping the Patient Determine and Achieve Readiness” (Chapter 3), once a decision to proceed with pump therapy occurs, new educational objectives emerge:
• Establishing goals
• Learning carbohydrate counting (if this is new to the patient)
• Calculating insulin-to-carbohydrate ratio(s) (ICR) (if this is new to the patient)
• Calculating the correction (sensitivity) factor(s) (CF) (if this is new to the patient)
• Managing hyperglycemia and hypoglycemia
• Choosing and inserting infusion sets
• Coping with lifestyle issues, sick days, exercise, supplies, and travel
A patient reference published by the American Diabetes Association, Insulin Pumps and Continuous Glucose Monitoring (Kaufman 2012) can be of great assistance to your patients as they learn the details of pump therapy.
Review or establish appropriate blood glucose and A1C targets with the patient at this time (Tables 2 and 3) (ADA 2013). Emphasize that pump therapy does not guarantee an automatic improvement in control but may make achieving control easier while providing a more flexible lifestyle. The responsibility for the improvements patients make using this new tool rests in their hands. Patients who are not doing well on MDI therapy may embrace the greater lifestyle flexibility offered by insulin pump therapy and become willing to put forth the effort needed for success.
| TABLE 2. Glycemic Recommendations for Nonpregnant Adults with Diabetes* | |
| Preprandial capillary plasma glucose (mg/dl) | 70–130* |
| Peak postprandial capillary plasma glucose (mg/dl) | <180* |
| A1C (%) | <7* |
| Goals should be individualized based on: • duration of diabetes • age/life expectancy • comorbid conditions • known CVD or advanced microvascular complications • hypoglycemia unawareness • individual patient considerations | |
| *More- or less-stringent glycemic goals may be appropriate for individual patients. Postprandial glucose may be targeted if A1C goals are not met despite teaching preprandial glucose goals. Postprandial glucose measurements should be made 1–2 h after the beginning of the meal, generally peak levels in patients with diabetes. |
TABLE 3. Plasma Blood Glucose and A1C Goals for Type 1 Diabetes by Age Group*
Discuss how critical it is for the patient to keep detailed records during the prepump education and pump start-up periods, which could last 1–4 months or longer. SMBG should include frequent pre- and postprandial blood glucose checks, at least four times a day, including one middle-of-the-night check around 3:00 a.m.
For enhanced pattern recognition purposes, ask the patient to also record factors that affect blood glucose, such as:
• Dietary intake, including grams of carbohydrate at each meal and snack
• Insulin doses (basal rates and bolus doses)
• Exercise: intensity, duration, and time of day
• Stress
• Illness
• Menstrual cycle
Patients who are already performing active self-management with MDI make the transition to pump therapy fairly easily. The challenges lie in what is common to both MDI and pump therapy—learning carb counting, planning ahead, adjusting doses for lifestyle issues, etc.
Patients Who Are Using Continuous Glucose Monitoring
CGM is another tool that may be helpful to you in determining your patient’s pattern of blood glucose control and deciding on initial pump basal rate(s) and bolus doses. Keep in mind the CGM measures glucose in interstitial fluid, not blood, so the values obtained at the same time from CGM and SMBG may not be identical. Refer to Chapter 6 for more on CGM.
Remind the patient of the learning curve associated with something as new and detailed as pump therapy initiation. Today’s “smart pumps” allow for easier determination of appropriate bolus doses and decision-making associated with pump therapy, but even the smartest of pumps cannot replace knowledge of the “hows” and “whys” of diabetes education and management. Make assurances that with time and experience, the patient will earn the freedom of being able to interpret his or her results and make safe self-management decisions using their insulin pump.
Carbohydrate Counting
It is essential that the patient, or parents if the patient is a child, learn and use advanced carbohydrate counting skills for several weeks or months before beginning pump therapy. It is both the prescribing clinician’s responsibility as well as the potential pump user’s responsibility that the prospective pumper has proficiency in advanced carbohydrate counting. Mastery of advanced carbohydrate counting skills requires instruction from an RD, preferably a CDE with pump therapy experience, and usually takes a few weeks to learn, depending on the patient’s history and abilities.
A person’s knowledge of carbohydrate counting and their comfort level with adjusting prandial (bolus insulin doses) will provide a foundation for success with insulin pump therapy. Many HCPs and prospective pumpers alike do not realize that this is the responsibility of the pump prescriber and pumper/parents. Teaching advanced carbohydrate counting skills is not the responsibility of a contracted per diem pump trainer or pump manufacturer employee (sales representative, territory manager, clinical education specialist, clinical manager, etc.) on the day of the pump therapy training or initiation. At this point, it is too late in the process to begin teaching carbohydrate-counting methods and concepts. Ideally, a prospective pumper should be able to demonstrate advanced carbohydrate-counting skills weeks or months BEFORE beginning pump therapy.
After initial review with the prospective pumper/parents, use follow-up session(s) as necessary to validate the patient’s/parents’ ability to count carbohydrate grams accurately. For additional information, refer to the American Diabetes Association book Practical Carbohydrate Counting: A How-to-Teach Guide for Health Professionals (Warshaw 2008). Although some pumps offer a carbohydrate gram database of commonly eaten foods, every pump patient should know how to accurately count carbohydrate grams of their favorite foods and be able to manually calculate a bolus insulin dose based on their specific insulin-to-carbohydrate ratio(s). Smartphones and thinkpads allow the downloading of a variety of useful carbohydrate applications that serve as a reference source for unfamiliar foods or restaurant meals. Some pumps offer the ability for the user to build a personalized food database of commonly eaten favorite foods and beverages and then program these as preset amounts with user-assigned names, such as “pancake breakfast” or “dinner salad.”
Another innovative pump option allows the user to simply input the meal items to be consumed; the pump adds the carbohydrate grams, and based on personalized information programmed by the user, calculates the appropriate carbohydrate bolus. Regardless of the manner in which a pump user totals his/her meal and snack carbohydrate amounts, it is essential that the user understand how to use an insulin-to-carbohydrate ratio(s).
Food labels provide the total carbohydrate grams, but if the patient is not accurate in knowing the carb amounts of the portions s/he is eating (i.e., adding up the total grams of carbohydrate in their meal or snack), the bolus insulin dose will not be correct. Stress the importance of accurate measurements and knowing how to use insulin-to-carbohydrate ratio(s) consistently.
There are countless stories of “pump therapy failures” or people whose pump therapy “just didn’t work right," etc. Many of these disheartening tales of failed pump therapy can easily be traced to lack of carbohydrate-counting skills coupled with inaccurate basal doses, or, worse yet, one constant hourly basal rate for 24 hours. There are even cases of people using an insulin pump with a set bolus dose per meal (often referred to as “a very expensive insulin pen or syringe”) without any regard to the amount of carbohydrate to be consumed. Again, it is essential that the patient or parents if the patient is a child, master carbohydrate counting before beginning pump therapy. It is a must for successful pump therapy.
For specifics on calculating insulin-to-carbohydrate ratios, see Calculating Insulin-to-Carbohydrate Ratios in Chapter 5.
Is the Patient Ready?
A prospective pump candidate should be adept at answering the following questions related to carbohydrate counting and insulin pump therapy without hesitation:
1. Do you know which foods contain carbohydrate?
2. How do you know how much carbohydrate you eat? (i.e., how do you count carbohydrate?)
3. How do you determine your premeal insulin doses?
4. What is (are) your insulin-to-carbohydrate ratio(s)?
5. Do you know how long your insulin (dose[s]) lasts?
6. How do you treat your high blood glucose levels?
7. What is (are) your correction (or insulin sensitivity) factor(s)?
8. How do you treat hypoglycemia?
Hyperglycemia
Remind the patient that the pump uses only rapid-acting insulin, and if there is an unexpected or accidental interruption of basal insulin delivery or an inaccurate or missed bolus, hyperglycemia can occur. Other causes of hyperglycemia during pump therapy include infusion set issues, such as cracked or broken tubing or tubing that has become disconnected from the pump or infusion site; or leaving the infusion set in (or pod on) too long. Expired insulin, or insulin in the pump cartridge/reservoir that has been exposed to heat and become less effective, can lead to elevated blood glucose levels. Ignoring warnings or alerts for a low or dead battery, illness, stress, onset of menses, and a change in pump settings with time zone changes can also cause hyperglycemia.
You will be surprised (disheartened) at how many patients with type 1 diabetes are not familiar with ketones (cause, treatment, and prevention) and the use of ketone test strips. Educate your patients on the importance of obtaining ketone test strips, when to use them, and to make sure they periodically check their expiration date. Although ketone test strips are available over-the-counter, your patient may request or require a prescription for insurance reimbursement. Blood ketone strips require a meter. Now is a good time to provide a (new) prescription for a vial or pen of long-acting insulin. Also, make sure the patient has rapid-acting insulin readily available in case of infusion site or pump issues/malfunctions. Stress the importance of carrying a spare infusion set or pod. Many people find it upsetting to know they need to always carry their “emergency” or back-up “kit," but the first time a pump patient experiences severe hyperglycemia during pump therapy, they quickly appreciate the importance of being prepared.
Hypoglycemia
Education on hypoglycemia management includes a review of the causes, prevention, and treatment. A review of symptoms at this time is also helpful. Remind the patient that the insulin pump does not “think” and cannot prevent hypoglycemia. A miscalculated bolus dose (which can also be a result of inaccurate carb counting), “stacking insulin” (see Chapter 5), inaccurate basal rates, changes in pump settings due to time zone changes, and planned or unplanned exercise can cause hypoglycemia.
For mild to moderate hypoglycemia, teach and emphasize the Rule of 15:
• Treat hypoglycemia with 15 g fast-acting carbohydrate
• Check blood glucose after 15 minutes
• Repeat the treatment as needed
Every insulin-using patient should have a glucagon prescription. Instructions on its use should be provided to the patient’s family members, friends, and/or significant other(s) (including coworkers). This information should not be new to the patient or to the people around him or her.
Additionally, now is also a good time to review the importance of wearing easily visible medical identification. There are many choices, including inexpensive necklaces, bracelets, charms, and pendants for both women and men, as well as the option of more expensive and/or custom-made engraved medical jewelry. Again, this should not be new to the patient, but is often an overlooked yet very important factor in living with diabetes.
Infusion Set Insertion
The patient may have already observed the insertion and removal of an infusion set when deciding whether or not to try pump therapy (see Chapter 3, Pump Candidate Basics). If not, the patient should see a demonstration, and may benefit from a practice insertion, especially if s/he is anxious about inserting or wearing an infusion set. During pump start-up, the patient will learn how to prepare the skin and insert the infusion set. Pump manufacturer personnel also provide specific instructions and detailed information to pump patients about infusion set insertion procedures.
The abdomen is the preferred infusion site because it offers a consistent rate of absorption. However, pump patients have had success using other subcutaneous sites, e.g., the upper hip/buttock, thigh, and upper arm. Teach patients to avoid inserting the set within a 2-inch diameter of the navel, at the waistline or belt area, or in any area where clothing would rub against or constrict the site.
Infusion sets must be changed every 1–3 days (1–2 days for metal/steel and 2–3 days for Teflon or soft cannula) to prevent infection and scar tissue buildup, which can lead to occlusions and reduce or interrupt delivery of insulin. The site should be rotated every time the infusion set base or pod is replaced, usually from one side of the body to the other, and ½ to 1 inch away from a previous site. The patient must check the site at least once daily for redness, tenderness, and tape or dressing placement. Encourage patients with long-term diabetes, or those with possible long-term use and resultant scar tissue of their abdominal area from injections, to consider alternative subcutaneous infusion sites. Alternative sites include the upper arm, upper thigh, and upper buttocal area. Patients who have been using CGM also may have favorite injection sites and will have limited choices for pump infusion site placement. It is important to emphasize site rotation and adherence to frequent (2–3 day) site changes. You should check a patient’s infusion sites at every visit to be sure the patient is not developing lipohypertrophy, which often results from inadequate site rotation.
Patch/Pod Pump Infusion Set
Presently, a patch pump infusion set is of the soft cannula type and would be inserted similarly to an infusion set base that has connecting tubing. The self-adhesive tape for a pod pump has stronger adhesive to prevent dislodgement during activities or water exposure. Newer “modular type” models on the horizon may require only the infusion catheter to be replaced, allowing the pump pod to be reused and thus, reducing the expense of replacing the entire pod.
Steps for Infusion Set Insertion
1. Wash hands with antibacterial soap.
2. Assemble the infusion set supplies in a well-lit, clean workspace.
3. Prepare the infusion site using an antibacterial soap or solution or a commercial product, such as an IV Prep pad, Betadine pad, Betadine solution (iodine), or Hibiclens (chlorhexiden). Allow the skin to dry naturally. Anxious children and apprehensive adults may benefit from the use of a topical analgesic (including ice, a cold spoon, or a cold beverage can/bottle) to numb the skin before inserting the infusion set. Products to reduce discomfort from the infusion set base or pod insertion include over-the-counter creams, such as LMX4 and Numby Stuff, and a prescription cream called EMLA. Pump manufacturers can provide a list of commonly used skin prep products.
4. Follow the manufacturer’s instructions for the infusion set insertion and needle removal (if using a Teflon cannula set).
5. Secure the set/pod to the site with the sterile self-adhesive tape/dressing.
6. Follow the manufacturer’s instructions to attach the tubing and bolus insulin to fill the cannula.
A metal/steel needle set may be felt, whereas a Teflon cannula set will not. If a set becomes uncomfortable after it is in position, it should be removed and discarded, and a new one should be inserted in a different site. If the site becomes red, swollen, irritated, or painful, the patient should remove and discard the set and rotate the site. The set should also be changed if blood appears in the tubing.
Optional Saline Trial
An optional saline trial can be done with a loaner (or demo model) pump while patients are deciding whether a pump is the right tool for them or after the pump is purchased and delivered during the pump preparation period. A saline trial may help the patient decide which pump to choose (see Chapter 2). People who are unsure about “being attached to something 24 h a day” or have anxiety about infusion set insertion may find that wearing a pump with saline allays fears and concerns. A saline trial also provides the patient the opportunity to learn the functions of the pump (the “buttonology”) without feeling the pressure of “If I press this button, I might make a mistake.” The insulin start that follows a saline trial may serve as a review of the technical training of the pump initiation process. This may be beneficial to those patients who are not quick learners or who express nervousness or anxiety about their actual pump start.
A saline trial should not be mandatory. MDI therapy must continue while wearing a saline pump; therefore, the patient does twice the work without enjoying the flexibility or freedom associated with pump therapy. And a patient who is excited about pump therapy is impatient to get started. A pump patient who is required by his or her clinician or CDE to wear the pump with saline first may resent the delay in the pump start and view it as a waste of time. The clinician and patient, or parents of the pediatric patient, should decide together if a saline start is truly appropriate. Saline requires a prescription, which the prescribing physician must provide to the patient.
Lifestyle Issues and Wearing the Pump
Many prospective pump users hesitate or neglect to ask about lifestyle concerns; therefore, the healthcare professional must take the initiative and include this information in the pump education process.
Daily Wear
The pump can be worn by several different means, including a clip, a case (leather, vinyl, or plastic) with or without a built-in clip or belt loops, or inside clothing such as thigh or leg garments, boxer shorts, lounging pants, and slips with pump pouches or pockets. A cotton infant sock is another option: the pump fits into the sock easily and can be worn in the side or cup of a bra, under control-top pantyhose or other shapewear-type undergarments, or pinned inside clothing. Some patients wear the pump in the top of their foot sock with long infusion set tubing under their slacks/trousers and use a remote feature or cross their legs and use the touch bolus button to deliver bolus insulin as needed. Another option is to sew pockets into the seams of garments or use Velcro for removable pockets. There are companies that manufacture devices that even roll up the pump tubing (refer to Chapter 8, Forms and Resources). Ask the pump patient in training to think ahead about wearing the pump with various types of clothing and in different situations, such as getting dressed and using the bathroom (toilet). An insulin pump pod, or “tubeless” pump is attached directly to the skin and does not require use of a case or clip.
Sleeping
Every prospective pump user wonders what to do with the pump during sleep. The patient may want to try wearing the pump inside the pocket of pajamas, a nightshirt, a nightgown, or boxer shorts. Another option, depending on the length of the tubing, is placing the pump in a specific location, such as under the pillow or on a night table. The pump can also be clipped to a sheet or blanket or placed freely in the bed. Longer tubing provides greater flexibility for moving and turning. Reassure the pump patient that even if the tubing is knotted upon awakening, insulin delivery will not be disturbed. The infusion set/pod dressing or tape secures the infusion set safely to the site.
Use of an electric blanket can affect the potency of insulin, especially if the pump is directly on the heating coils. Pump users need to consider this if their fasting blood glucose is erratic without explanation.
Bathing/Showering
Pumps are waterproof or water resistant—check with the pump manufacturer for specific guidelines. Even if the pump patient is not planning on wearing the pump while bathing or showering, pumps have been known to fall in the toilet. With a disconnect infusion set, the pump can be disconnected for up to 1 h and reconnected after bathing or showering. Remind the patient that insulin is very heat sensitive; soaking in a hot bath or whirlpool or using a sauna while wearing the pump is not recommended.
Intimacy/Sexual Activity
To wear the pump or not during sexual activity is the patient’s choice. If the patient wants to keep the pump connected, longer infusion set tubing may be recommended or preferred. The patient should be reminded to reconnect his or her infusion set and pump and the infusion site should always be checked to make certain the set base has remained intact. See Intimacy/Sexual Activity for additional information.
Sports/Physical Exercise
Advise the patient that an insulin pump can, and should be worn during exercise and physical activity, and even professional athletes keep their pumps attached while engaged in their sport of choice. Specific suggestions for wearing the pump and guidelines for adjusting insulin doses during exercise are provided in Exercise and Physical Activity.
Medical Procedures, Sick Days/Illness, and Hospitalization
The specific medical procedure (CAT scan, X-ray, etc.) will determine whether or not the pump should be worn. Patients may also be advised prior to the medical procedure or test if it is appropriate for the pump to be exposed to the medical test or procedure. Remind the patient that if the pump is to be disconnected longer than an hour, it may be necessary to make adjustments in insulin doses.
Advise patients that, similar to MDI therapy, lengthy medical procedures and sick days and illness often require adjustments in insulin doses and the same guidelines will apply. A prospective pump patient may ask if they can wear their pump while ill—reassure the patient that illness does not require the pump to be disconnected, but in the case of severe illness or if the patient is incapable of operating their pump, s/he may require the assistance of another person and/or a temporary return to MDI therapy. A back-up, or “pre-pump” plan is essential.
Refer to Managing Sick Days and Medical Procedures , for specifics on managing pump therapy during medical procedures, sick days, and hospitalization.
Patient Support System
Pump therapy initiation can be an emotional process for the patient. It may have taken a patient several months or even years to make the decision to choose pump therapy. In addition to your support and encouragement, the patient’s personal support system is an important factor in successful pump therapy. Spouse/significant other and family encouragement will help the patient in his/her pump education and initiation process. The patient may choose to also involve friends and co-workers, and may invite them to co-attend pump support group meetings, or at the least, may inform them of this life-changing decision. Diabetes-focused consumer magazines and publications are other materials the patient may find helpful. Social media are another avenue of support, and the availability of information on the internet is astounding. There are many internet resources related to insulin pump therapy, and patients may find or be directed to various insulin pump sites and blogs. You can also provide reliable credible resources (see Chapter 8, Forms and Resources). Pump manufacturers offer support via internet, print, and telephone and can serve as a great resource to a new pump patient.
Ordering the Pump and Supplies
Once you and the patient have decided to initiate pump therapy and the patient is close to “being ready” (refer to preceding chapters), the next step is to order the pump and supplies. Insurance companies and pump manufacturers vary in the pump order process. Pump companies have designated personnel who walk the patient through the order process. Depending on the company’s policies and procedures, as well as those of the patient’s insurance company, the process can take anywhere from a few days to a few weeks. A signed order or prescription for the pump and initial supplies (infusion sets or pods, cartridges/reservoirs, tape, skin prep) from the healthcare professional is required, and additional paperwork may be requested. This may include, but is not limited to: a letter of medical necessity, usually with “check-off boxes” related to the patient’s diabetes control status and/or complications; SMBG data maintained by the patient or available from you; and recent and past A1C results. Additionally, the pump order may also include instructions for the pump start and initial settings, including blood glucose targets, basal rate(s), insulin-to-carb ratio(s), correction factor(s), and duration of insulin action (“insulin on board”). A prescription for saline is required if a saline pump start is desirable, and a prescription for rapid-acting insulin, taking into account the additional amount needed for tubing, is a must.
A logistic consideration is the designation of the pump delivery. Some clinicians prefer the pump be delivered to them rather than to the patient, as some patients have self-initiated without the knowledge of their prescribing physician and without any training, with disastrous results. In this case, the healthcare professional is responsible for informing the patient that the pump has been delivered and training by the pump manufacturer (CDE trainer) can be scheduled. Another “order” is to designate who will “follow” the patient, i.e., adjust insulin doses during pump initiation, usually the first few weeks. You must decide if you will be in frequent communication with the patient during the initiation period, or if you prefer the pump company to manage this. Pump manufacturers may offer initial follow-up as a service provided by their staff or per diem CDE.
Pump Supplies
The initial pump order includes not only the insulin pump, but also the supplies necessary for the patient to get started. These include cartridges/reservoirs; infusion sets or pods; dressing/tape, such as IV 3000, skin prep, such as IV Prep, and battery. An initial pump order also includes user guide instructions, such as online tools, DVDs, and printed booklets.
Most pump orders request a 3-month supply, so keep this in mind when completing the initial pump order or prescription. Consider that the cartridges/reservoirs and infusion set/pods will be changed every 1 to 3 days, so do the math. On the average, an infusion set is changed every 2 to 3 days; in one month, the pump user may need 10 to 15 cartridges/reservoirs and infusion sets/pods, and a 3-month supply may be a standard order. There may be more set and site changes initially as the new pump user may “lose” some sets during their learning curve. The same is true for the insulin. Remember that the tubing contains insulin, so when the patient changes their infusion set tubing, the insulin in the tubing is also discarded. One inch of tubing contains 0.3 to 0.5 units of insulin (depending on the brand of infusion set), so discarding 43″ tubing every 2 days results in a loss of over 250 units of insulin per month. Over time, some patients have learned to change only the actual infusion set base, leaving the tubing attached to their cartridge/reservoir until the cartridge is depleted. As of this publication date, the rapid-acting insulin analogs are FDA-approved for use in an insulin pump cartridge/reservoir for several days, including: Apidra®, 48 hours; Humalog®, up to seven days (three in the tubing); and NovoLog®, up to six days (sanofi-aventis 2009; Eli Lilly 2011; Novo Nordisk 2002–2011). But a decrease in efficacy, resulting in escalating hyperglycemia, can occur if the insulin remains in the cartridge/reservoir too long; cautionary advice is recommended. During initial pump starts, recommend patients “change everything” every 2 to 3 days. This will help patients to learn proper procedures and improve their technique, and will also eliminate the possibility of ineffective insulin as a cause of hyperglycemia. Refer to Infusion Site and Tubing Concerns in Chapter 6 for additional information.
References
American Diabetes Association: 2013 Clinical practice recommendations. Diabetes Care 36:S11–S66, 2013
Eli Lilly and Company: Humalog (insulin lispro injection USP [rDNA origin]) for Injection Prescribing Information. Indianapolis, IN: Eli Lilly and Company, 2011
Kaufman FR, Westfall E: Insulin Pumps and Continuous Glucose Monitoring: A User’s Guide to Effective Diabetes Management, Alexandria VA: American Diabetes Association, 2012
