Successful pump use depends on proper care and protection of the infusion site. The information in this brochure comes from longtime pump users and experienced health care professionals. It should help you successfully prevent or solve the most common problems: skin irritation at the infusion site and poor "sticking" of tape. Information about site infections and insertion problems have been included as well. Even though these problems are far less common than irritation and tape problems, they can be serious for those who do have them.
The Basics: Site Selection And Rotation
Proper infusion site selection and rotation promotes predictable insulin absorption and protects infusion sites from undesirable tissue changes such as hardening and bumps. The preferred body area for placement of the infusion set for pump users is the abdomen. Insulin absorption from this area is the fastest and most predictable, as compared to other body areas. However, using ALL available sites in some predictable pattern of rotation is probably wise. Some longtime pump users who have used only their abdomen for all their years on the pump are now reporting significant tissue changes and difficulty finding sites on the abdomen that still absorb well. The upper outer thighs and hips are both areas that also work reasonably well for pump users. The more sites you use, the less often any one site is injected. This is your best assurance of keeping tissue healthy over the years.
Whichever body area you are using - abdomen, thigh, hip or even arm, the exact site within the area should be changed each time the infusion set is changed. The new site should be at least one inch away from the previous site.
It is best to use the available sites in a predictable pattern: for example, starting at the upper right hand corner of the abdominal area and then moving one inch to the left with each change until reaching the left hand margin of the area. From there move down one inch to start a new row and move to the right in 1" steps and so on. Following a predictable pattern assures that the longest possible time will pass between uses of the same site. Avoid the area immediately around the belly button and any surgical scars that you may have when picking infusion sites.
Late in pregnancy, when the abdomen becomes too firm to pinch up subcutaneous fat, the upper outer thigh, or hip may be used instead. The arm is also a possibility, but many people find dealing with the catheter tubing quite awkward with an arm placement. Switching to these alternate sites may result in some changes in blood sugar control due to changes in the speed of insulin absorption. Consult with your doctor or diabetes educator if this happens. One answer may be to take boluses earlier, allowing more time to elapse between taking the bolus and eating the meal. Infusion set and site should be changed at least every 48 hours during pregnancy. Your team may even want you to change your set every day as the pregnancy progresses. Make sure you know and follow the advice of your team.
Tissue Changes May Impede Insertion
If skin or underlying tissue on the abdomen feels hard, solid or tough, you may have an area of "hypertrophy," or tissue buildup caused by injecting insulin repeatedly into the same area. These areas should be avoided to give the damaged area time to heal. One month is a very conservative estimate of the time required for the tissue to return to normal. If you inject into these areas before the tissue has returned to normal, you may have poor or unpredictable insulin absorption, and you may make the tissue changes even worse. If you have trouble inserting your infusion set into an area due to hardening of the tissue, use another softer area.
The infusion site must be clean and dry before inserting the needle or Sof-setTM. If the site isn't clean, potentially serious infections are more likely. If the site isn't dry, it may contribute to problems with tape staying in place. Various methods of cleansing the site can be used. Washing with a mild antibacterial soap such as Dial, either alone or followed by wiping with alcohol is adequate for most pump users.
About one pump user in ten is prone to developing infections at the infusion site. If you begin to have problems with site infections, adding an antiseptic to your site preparation routine is advisable. The following products are preferred by many pump users and health care professionals.
Hibiclens (Stuart Pharmaceuticals)
An antibacterial wash similar to PhisohexTM. Available at pharmacies.
Betadine (Purdue-Fredrick, Inc.)
A medicated antibacterial agent. Available at pharmacies as a wash or ointment.
The Sof-setTM dressing contains a mild antibacterial agent. To get the same protection with metal needle sets, you might try dabbing BactrobanTM (SmithKline Beecham), PolysporinTM or NeosporinTM (Burroughs Wellcome) over the needle at the insertion site and then taping over it as usual when thoroughly dry.
If infusion site infections are still a problem in spite of careful cleansing and use of antiseptics, you may be a carrier of certain bacteria such as "staph" (staphylococcus). If you feel you may be a carrier of the "staph" bacteria, consult your doctor who may prescribe an oral antibiotic to help prevent or control infections.
Tapes And Dressings
A transparent dressing which is compatible with most skin types and is reported to "stick" well. Polyskin comes in a convenient 2" x 2.7" size that is perfect for covering the infusion set. Available from MiniMed Sales Order (800-843-6687), or MiniMed's OnLine Store.
The tape will be more comfortable if a hole is cut in the center. This can be done by folding the tape in fourths and cutting off the folded corner to accommodate the Sof-setTM, as shown in the illustration.
TegadermTM or TegadermHPTM (3M)
A clear tape dressing similar to Polyskin. The Tegaderm HP is intended for people with allergies and sensitivities, it adheres well when exposed to moisture. Tegaderm and Tegaderm HP is available at pharmacies or through medical supply houses.
IV 30OOTM (Smith and Nephew United)
IV 3000 is a sterile dressing which keeps the covered area dry. IV 3000 pulls away from skin and hair easily during removal when the tape is stretched. IV 3000 comes in several sizes, the recommended size for insulin pump use is 2 " x 2¾". IV 3000 is available from Smith and Nephew United (800-876-1261).
CompeedTM (Bruder Medical Products Division)
Compeed has good adherence when wet and is non-irritating. Available from Bruder Medical Products Division (404-425-5322).
HypafixTM (Smith and Nephew United)
A white roll tape with very good adhesive, however is not transparent. Hypafix can be used to cover the infusion set, to tape down the edges of another dressing, or to secure a safety loop. It is designed for sensitive skin. Hypafix is available at specialty pharmacies or from Smith and Nephew United (800-876-1261).
Hy-Tape, The Original Pink Tape (Hy-Tape Corporation)
A water proof roll tape with a zinc oxide adhesive base. Soothing to delicate skin and good for extended wear. Comes in 1" and 2" widths. Hy-Tape can be used in the same manner as Hypafix and is available from Hy-Tape Corporation (800-248-0101).
Transpore (3M) or Dermicell (Johnson and Johnson)
These clear roll tapes stick well and are used by many pump users to secure safety loops.
Silk tape comes in ½" and 1" widths. It both sticks extremely well and comes off fairly easily when pulled. Like Hypafix, it is not transparent. Special care should be exercised to monitor the infusion site if it is used as the primary dressing over the infusion set. Pharmacies can order silk tape from various manufacturers.
Some people who have extremely sensitive skin prefer paper tape next to the skin. Examples are Micro-pore and Duropore. However, paper tape does not adhere as well as other products on some people. If this is the case, try securing the edges of paper tape with another product that sticks better. Paper tapes are available from pharmacies and medical supply houses.
Skin Barriers (Skin Prep, Skin Tac "H" and ShieldSkin)
The following skin preparations will help prevent irritation and sensitivity problems by placing a barrier between your skin and the tape's adhesive. These products are also excellent to help tape "stick" better. Be sure that the infusion site dries thoroughly after applying these products, before trying to apply a tape or dressing.
Skin-Prep (United, Division of Howmedica)
A protective dressing for sensitive skin which is wiped on before placing tape onto the skin. Available at pharmacies or through United, Division of Howmedica, Inc. (813-392-1261). A similar product called ShieldSkin is made by the Mentor Company.
Skin Tac "H" (Mason Labs, Inc.)
A liquid adhesive which is brushed on the skin before applying tape. Available at medical supply houses or through Mason Labs, Inc. (800-523-2302).
When To Change The Infusion Set
It is best to change your infusion set before a meal to allow the bolus to clear away any tissue from the cannula or needle. Do not change the infusion set before bed as you will need to be awake to know if the set is improperly inserted.
The infusion set and site should be changed frequently and regularly. A general rule of thumb is that a metal needle should be changed at least every two days, while a Sof-setTM should be changed at least every three days. However, your doctor or educator may recommend a different schedule based on your particular situation. For example, many doctors recommend more frequent set changes during pregnancy. Make sure you know and follow your team's advice about frequency of set changes.
Your set and site should also be changed whenever you notice any irritation or discomfort at the infusion site and always when you have two unexplained high blood glucose readings in a row. Also, leaving the set in for too long may promote hardening of the skin tissue leading to poor absorption of insulin.
Troubleshooting Site Problems
A more common problem than infections is skin irritation at the infusion site. This may be caused by sensitivity to the tape being used, or by friction from the needle or plastic parts of the infusion set. Different solutions can be implemented if irritation occurs.
If the irritation appears around the edges of your tape or dressing, try lifting the edges slightly all around the dressing. This creates a new contact edge and often alleviates the problem.
If the irritation appears wherever the tape touches the skin, you may be sensitive to the tape's adhesive or material. Removing tape adhesive from the skin with a product made for this purpose may ease the irritation (Unisolve, comes in packs of fifty applicator pads, Smith and Nephew United, 800-876-1261). You may also try a different tape. The different material or adhesive used in another brand may solve your problem. Switching tapes may also be the simplest way to solve sticking problems. Several brands of tape recommended by pump users are listed on page six. Remember, what works well for another person, may or may not work well for you. Keep trying until you find the best routine and products for you.
Irritation from the plastic parts of the infusion sets may be prevented by first putting a layer of the tape or dressing of your choice against the skin, and then insert the infusion set through this. Once the set is in place, secure it with a second layer of tape. Metal sensitivity is another possible cause of irritation. If you experience irritation in areas that come in contact with a metal needle, try the Sof-setTM.
And a final word of wisdom about irritation
Pump users and health care professionals alike stress the fact that "if it's noticeable, something is wrong." Check or change your site at the first sign of irritation or discomfort. Irritation, discomfort or pain may be the first sign of a developing infection. Taking action immediately will keep little problems from turning into big ones.
Tape Sticking Problems
If your tape or the Sof-setTM dressing is not sticking properly, try holding your hand over the tape for 1-2 minutes after application. This warms the tape and may improve adhesion. This technique can be used with any tape or dressing.
One of the most common causes of poor sticking is perspiration. This is a particular challenge for people who are physically active or live in hot climates. If this occurs, try applying antiperspirant around the insertion site, and under the area that will be covered by tape or dressing. Avoid the actual insertion site to prevent antiperspirant being carried into the skin when the needle or cannula is inserted. Make sure the antiperspirant has dried completely before proceeding.
If perspiration has moistened the tape or dressing holding a metal needle infusion set in place, you may be able to remove the tape without disturbing the needle. If so, dry the area thoroughly and retape.
Remember - Always replace the Sof-setTM if the dressing begins to peel. A loose dressing may allow the cannula to become dislodged.
Sof-SetTM Fundamentals - avoiding crimping or bending
Crimping is usually the result of improper insertion. If using Method 1 described in the Sof-setTM package insert, the set MUST be inserted in a quick motion. Keep the index finger on the needle hub during insertion to assure that sufficient pressure is applied as the needle is pushed in. Pinching up the skin helps to stabilize it for quick, smooth insertion. If you have problems inserting quickly, try Method 2 described in the package insert.
Bends can be caused by either improper insertion or dislodging of the tape due to poor sticking. You can stabilize the cannula to prevent dislodging of the tape by using a second piece of tape that covers the needle hub. This can be particularly useful during exercise and sports when perspiration may reduce tapes' sticking properties. Resistance from muscle tissue can also cause an "L" shaped bend in the cannula.
Important Sof-setTM Tip: Before removing the introducer needle, give it a slight turn. This helps make sure the cannula stays in place as the introducer needle is taken out.
Remember: Proper technique is vital. Review instructions in the package insert.
Discomfort During Insertion Of Infusion Set
A small number of people experience discomfort when first inserting the infusion set. Although rare, this problem is important to address since it would be a problem with conventional injections as well. Some nurses recommend rubbing the area with ice to numb it slightly before inserting the needle.
Another recommendation is the use of a product called Emla Cream, (Astra USA, 800-228-EMLA) a topical analgesic (pain killer). The cream is applied one hour before the infusion set and washed off just before inserting the infusion set. The site should be clean and dry before insertion as previously described. Complete instructions for use come in the package insert for Emla Cream. If you are experiencing pain on insertion of the infusion set, discuss the use of Emla Cream or other possible solutions with your physician or nurse educator.
If any of the products mentioned in this brochure are not available at a local pharmacy, ask your pharmacist or try a medical supply house.
Note: Please call us at MiniMed if one brand of tape, antiseptic or other supplies have worked particularly well for you. We are also interested in how you have dealt with any skin or insertion problems. We will share this information with other pump users through updates of this booklet and through the MiniMed Newsletter.
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