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Expert
Please note
the information provided below is for your information only and does not
replace medical advice. Please check with your medical team before
making any changes to your diabetes regimen.
Diabetes Advocacy is proud to add
an Expert to our site. Jill Milliken is a Pump Expert who will be
providing us with information and is available to try and answer any
question you may have. If you have a topic you would like Jill to
discuss, please contact us at
Diabetes Advocacy.
For those with Disability
Tax Questions, we have also added a
DTC section for your
questions!
Kids and Infusion sets
by Jill Milliken
RN CDE
Insulin pump therapy is the gold
standard in pediatric type 1 diabetes management.
The pump is well accepted and has specific benefits over MDI in
this population adding to it’s increasing popularity amongst families of
children with diabetes.
There are also more choices for infusion sets than ever before adding to
the convenience of the therapy.
This article aims to assist parents and educators in choosing the
best infusion set for the child and troubleshoot common set problems.
Each type of infusion set has
it’s own specific benefits and considerations.
Assisting your child to choose the one that suits them the best
can eliminate untoward events or unnecessary frustration.
The following are some general suggestions when choosing an
infusion set.
Teach more than one type of
infusion set
Preparing to start insulin pump
therapy is the “teachable moment” for learning new things.
Training the use of more than one type of infusion in the
beginning can help later on if there are problems with the initial set
or you get caught in a situation where you have to use a set you are
less familiar with.
Age and infusion set
considerations
Young children under the age of
5 or 6 are best with the sillouhette / comfort set placed in the tissue
of the upper outer buttock.
There are several reasons for this including the “out of sight out of
mind” factor, the added subcutaneous tissue in this area and the fact
that these kids often “lead with their bellies” making that area more
prone to being bumped. Parents should learn to put the infusion set in
manually as opposed to using an insertion device.
Topical anaesthetics, ice or the back of a cold spoon can be used
to desensitize the area prior to insertion.
This type of infusion set is available in more than one cannula
length. Practice makes perfect in selecting the best insertion angle
from 15 – 35 degrees.
In school aged children the
preference for using the buttocks is less common.
Increasing independence with set changes and being away from home
for sleepovers, camp etc. means that these children can learn to place
their own infusion sets.
Lean children should use shorter length cannulas such as the quick set
6mm or a manually placed sillouhette / comfort set.
Teenage girls often prefer the
low profile placement of the sillouhette / comfort infusion set as it
can be inserted in front of the hip bone on the lower part of the
abdomen out of sight and in keeping with today's’ popular fashions.
Instruct them to pinch their skin up high when they place this infusion
set aiming the needle at the highest point of the pinch.
Any school aged child or teen
who can pinch an inch may find that a short cannula leads to frequent
bouts of dislodgement or poor absorption.
A 9mm cannula or angled infusion set is preferred.
Troubleshooting
The following are some
suggestions when troubleshooting infusion set problems:
- An infusion set should last 3
days, though in some children, rising blood sugars on day three can
indicate the need to change more frequently if it occurs
consistently. This may be due
to the combination of a low infusion rate and rapid healing often
seen in children.
- If your client is struggling
with dislodgement or site problems, it is important to evaluate
their technique in placing their infusion set including the use of
an insertion device.
- A kink in the tip of the
cannula may indicate an infusion set resting against a muscle. Use a
shorter length cannula, or angle the sillouhette / comfort infusion
set to a lesser degree upon insertion.
Kinks at the top of the set close to the hub are due to “set
migration” caused from added pulling on the tubing.
Either secure the site using the “sandwich technique” (see
inset) or use another piece of tape to secure a proximal loop of
tubing.
- Skin irritation under the
infusion set is common. This
can occur when the set is left in too long, gets wet and or there is
a sensitivity to the adhesive, skin prep product or cannula itself.
Rule out product sensitivities by
using only soap and water.
Sandwiching the set is the next step at isolating the cause
of the sensitivity. If it
truly is a cannula sensitivity and your client is using the Quick
set or Sillouhette / comfort suggest they try a sof set as the
cannula is made of a different material.
- Site allergy is more serious
and may require systemic medications to prevent an allergic
reaction. Localized site
allergy may be temporarily offset by the use of a topical
antihistamine such as Benedryl stick or lotion.
Talk to the physician about prescribing Atrovent for topical
use. One dose on the skin prior to infusion set placement has been
known to prophylactically prevent a skin reaction.
- Removing adhesives can appear
as a local site irritation the same way a raised red area commonly
occurs when removing a bandaid. Use baby oil or lotion to remove an
infusion set if this is the case.
If removing an IV 3000 dressing (see inset on sandwiching)
remove by stretching the dressing progressively until it peels off
easily.
- Long – term pump users may
experience “site fatigue”
from using the same areas over a long period of time. This scarring
and decreasing or variable absorption is preventable to a point.
There is no one type of infusion set that is better than
another one at preventing site fatigue.
A more important factor is good skin care. Explain to the
client that leaving their infusion set in too long,
surface skin infections after the set is removed or lack of
rotation of infusion areas are causes of site
fatigue. Each nursing visit should include an assessment of
the infusion sites and review site rotation and good skin care
techniques.
Pump Specific Psychosocial Issues
Jill Milliken RN
CDE
The following are
some commonly discussed psychosocial issues related to insulin pump
therapy.
- Realistic
expectations of what a pump will do.
It will not take diabetes away. If outstanding issues are present
relating to denial of the disease, the pump will make things worse,
not better. As the reality
of what pump therapy is vs what it isn’t unfold to the person with
diabetes, the opportunity presents itself for a “teachable moment”
in up-to-date diabetes care.
After the rose-coloured glasses come off and the picture becomes
clear, true motivation for change can be acted upon.
- Family
support for the new pump user.
Initiation of a pump is sometimes described as similar to bringing a
baby home from hospital. A
newness to the therapy can make people unsure of how they are doing
and frequent monitoring can interrupt usual routines ie) overnight
readings at 3 am until rates are set. Support therefore is key in
success of pump therapy.
- The
“Wearing Issue.”
For those people new
to insulin pump use, the thought of the pump being worn continuously
can be daunting. The pump must
be worn 24/7, 365 days a year. That being said, the trade off
of being perpetually attached goes hand in hand with freedom from
injections, mealtime flexibility and quality of life improvements.
The “wearing issue” should not overshadow the benefits of the pump
tried and proven. There was even a research study of pumps VS
Multiple daily injections that had to be cancelled midway because
the pump group refused to cross over! In fact, 97% of people who
start on a pump, stay on a pump! Kids can look at having a pump as
almost a “status” symbol. They become very proud of their pump! Some
kids even name their pumps.
One girl named her pump “Atlas” because in her words:
“it took the world off my shoulders.
Health professionals can sometimes focus too much on the
wearing issue because they themselves might find it inconvenient.
Some people may even be discouraged from using one for that
reason alone! It is always
helpful to remember who the person with diabetes is!
- Who here
has diabetes?”
Sometimes, someone in the family
other than the person with diabetes is very keen about the pump.
There may be a degree of pressure to conform to the request
by this family member to use a pump.
This is seen in kids where it is the parents who want the
child on a pump not the child. Sabotage can and does happen in
pumping therefore it is simply not safe if the user is not willing.
- Intimacy.
In adults of any age, the insulin pump can be seen by partners as an
encroachment on their territory, an unwanted “invader”. Similarly,
the pump user themselves can feel that their partner may see them as
fragile or susceptible to harm due to being a pump user. This is
absolutely not the case and this aspect of life must be discussed
early on in the process to allay fears related to intimacy and the
pump. Most couples simply disconnect the pump from their body during
intimacy. Solutions to early or current issues related to this can
include:
- Using
infusion sets which are “low profile” and disconnect right at
the site. Those with a hanging tube when disconnected can be
replaced by more discreet infusion sets such as the silhouette.
- Using an
infusion site area which is “out of sight out of mind”
such as the upper buttock.
- Taking
advantage of sight change times. Remember, the pump can be
disconnected for up to 2 hours anytime while “active”
- Taking a
pump “holiday” . Though
not commonly done, some people prefer to take a short pump holiday.
Voicing this may mean that they need a mental break from being
attached perpetually to the pump. If someone approaches their
provider about taking a “pump break” it should not be discouraged.
How can we – non-diabetics relate to their personal experience in
order to judge whether we want them to discontinue the pump for
awhile? In short, we should not. Yes, the reasons can be explored,
but once a consensus is reached, guidelines for the resumption of
injections should be given by their provider.
Overall, pump
users relate that pump therapy is a great success in their life. The
phrases often used are “in more control of my disease” and “I wish I
would have started on the pump sooner.” The feeling of success with pump
therapy is often so overpowering that people with diabetes wish to share
their experiences with others. Pump support groups are the result of
this enthusiasm and a testimonial for the benefits of insulin pump
therapy over other modalities of insulin delivery.
Case and point: how many
“Insulin Pen support groups” do you know of?
Ask our expert your diabetes related question!
ASK OUR EXPERT! Jill, CDE
My 19 year old
daughter has been wearing the pump for 10 years. Initially, infusion
sets and sites were no problem - she used the Quickset, changing every 3
days - good BGs.. She rotated sties (abdomen) carefully. She then
became very active, lean and muscular and switched to Silhouette, using
the longer and then the shorter cannula. After a time, sites often
"went bad" due to the bending of the cannula, so she changed to Sure T.
For the past year, she has used the Sure T, and was fairly successful.
For the past month, however, sites are "going bad" (soaring BGs) about
every day and a half. When she removes the set, there are lumps at the
site. She is still using her abdomen, and trying to rotate the sites.
Is she reacting to the metal needle? Is it possible to react to Humalog?
(she reports that she feels the insulin going into her body after a
bolus) Any suggestions about what to try next? We are desperate and
considering going off the pump!
Since your daughter has been on the pump for 10 years however, I
know she must have encountered these other issues and was able to
eliminate other causes. Lean
individuals do well with short cannula 13 mm silhouettes and since you
have also tried it, it may be a technique issue…when she pinches up the
skin, don’t “tunnel” or go to shallow of an angle as it may not be the
right type of tissue for insulin absorption.
Once the skin is pinched up, use a 30 degree angle to insert the
cannula. Once the pinch is
dropped, it will be in the right tissue.
Have you ever tried NovoRapid in the pump? Many
long-term pump users who had issues with sites found that using NR
improved things. Talk to
your pump educator or doctor about switching if you wish to try this.
There are some studies available which have shown improved sites
in pump users using NR
particularly those who were unable to achieve a full 3 days with one
infusion set using Humalog.
How do you get off the pump on your own if you do not
seem to get your physicians to understand your need for a pump break ?
I still have my pre-pump numbers, can I go with that ?
~Diane
Reasons for going off a pump may vary. They include everything from
malfunction, surgery, special occasion or any event or situation where
one may choose to discontinue the treatment for hours, days, weeks or
more. It is therefore a good idea to understand how to resume
injections. Every pump user should have their basal rates, insulin
to carbohydrate and insulin sensitivity (correction factor) written
down. Resumption of injections as mentioned below, cannot be done
safely without these key pieces of information.
Pump users are most often instructed to resume their pre-pump doses
of insulin, however; this can be dangerous for several reasons:
-they are most often using less insulin than they were on injections.
-their body is not used to large depots' of insulin.
-their weight may have changed since injections and therefore their
insulin sensitivity may have changed.
-because of the long duration of some insulins, resuming pump therapy
is easier if you are only using a rapid acting analog such as Novo Rapid
or Humalog.
Here are some considerations for pump therapy interruption whether it
is by choice or not.
1) Take care of your diabetes first, your pump second. You will
need insulin by injection in as short as only a few hours to prevent
"Accelerated DKA" which is a therapy specific issue. Frequent or
continuous monitoring of glucose is the only way to control this
situation from worsening.
2) For short periods off the pump such as 24 - 48 hours with the
intention of resuming the pump, you can take 6 injections of rapid
acting insulin around the clock. Do this by adding up your basal rate
for the each 4 hour "chunk" of time, add to that amount, any bolus
insulin for a meal or snack to this amount, then reduce this total by
about 10 - 15% at each injection. This total is your injection of rapid
acting insulin. ie) Joe uses 0.7u/hr which is 2.8 u over the 4 hours. At
breakfast he is 10mmol and has a correction factor of 1u/2mmol and a
carbohydrate ratio of 1u/15g carb. He is eating 60 g for breakfast. He
requires 2.8 for basal, 2 u for correction, and 4 u for his food.
All together the total is 8.8 u of rapid acting, reduced by 15% he
decides to take 7.5u. At bedtime, his sugar is 5.5 and his basal rate is
0.6u/hr. or 2.4u. Since Joe mowed the lawn in the evening he decides to
have a bedtime snack of half a sandwich and not take insulin for it to
be safe and injects 2u for his basal and sets the alarm for 2 am. This
is just an example, everyone knows their own diabetes best.
3) For longer periods than several days, you should talk to your
doctor or educator for resumption of long acting and rapid acting. If
your pre-pump doses were recorded prior to going on the pump, it is
prudent to reduce this dose and titrate your insulin upwards using your
correction factor. Frequent testing is key.
After resuming your multiple daily injection therapy, the pump user
must take a few things into consideration:
-you may need to have a higher bedtime glucose level than on a pump.
Therefore you may require changes to the way you approach meal
planning such as adding in snacks with higher carbohydrates and eating
at regular intervals.
-Your glucose may be more variable. Be prepared to test and act more
frequently.
-Your meals may require adjustments, you may not be able to "eat
whatever you want" without paying the price later with high blood sugar,
and weight gain.
In Summary,
For some individuals, these off pump considerations are still
worthwhile. Being connected 24/7 365 is by no means easy and those who
support pump users should be aware of the mental fatigue that may (or
may not be) improved by a short pump "vacation" For the pump user, try
to decide whether the psychological fatigue you are feeling relates to
using the pump or is in fact related to caring for your diabetes in
general - sometimes its' hard to deliniate which it is. For many people
who try a pump vacation, the benefits of their pump to their lifestyle
will become quickly apparent as they have become used to the freedom the
pump can provide, but for others who live off the pump like they did on
the pump, they will soon find out it's harder than they think to gain
the control they had over their diabetes. Whichever they choose,
it is always their choice, not their loved ones or health providers who
do not have to walk a day in their shoes. Doing it safely is key.
Back to Top
Ask the Disability Tax
Credit Expert
Please note that Barb is not a tax accountant. Tax law questions
should be directed to the appropriate professional accountant or lawyer.
I am a retired 61-year-old male who has recently been switched from
oral diabetic meds to two kinds of insulin to get my sugars under
control. I can no longer use the oral meds because my kidneys have been
damaged. I live on my pension and CPP. I want to apply for the
disability tax credit. I seem to meet the criteria, but I am not
certain. Does the credit apply only to people with Type 1
diabetes? Diabetes completely rules my life. I exercise a lot,
walking about 8000 steps a day (currently shooting for 10000). I am very
careful about what I eat. I test five or six times a day, and inject
insulin by syringe four or five times a day. Given the limited amount of
information I've shared with you, do you think it would make sense for
me to apply? I also suffer from chronic pain from psoriatic arthritis
and it is highly unlikely I will ever hold a job again. ~John,
BC
-
The DTC applies to
anyone who is dependent upon an external source of insulin that must
be injected via syringe or insulin pump to survive. People with Type
2 diabetes who are using insulin are qualifying for the DTC. The
process is the same as those living with Type 1 diabetes--download
form T2201 off of the government website (we have a link on the DTC
page) and fill it out. Have it signed by your physician and send it
in with your taxes. If you have been using insulin for a period of
years, you can ask to be reassessed to the year you started on
insulin or 2003 which ever came first. If you have been using an
insulin pump that date goes back to 2000. Your doctor may be sent a
second form asking for details of your care. This just needs to be
filled out accordingly and once it is signed then you will receive
your DTC for a specific period of time. After that time has elapsed,
you simply apply again.

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