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Re: [IP] set changes (a bit long)

At 07:16 PM 5/21/98 EDT, Glenda wrote:

>I've now been on the pump 1 week and am impressed with how good my numbers
>are.  I have changed the set twice and have had problems both times.  My BS
>immediately started going up and I changed the set 3 times each before I
>get it back under control.  Its very frustrating since I am following the
>by the letter and I am a nurse, so I know how to fill a syringe etc.  Is it
>just because I don't know what I 'm doing, or what??  I dread the thought of
>the next set change!!  It has really helped me gain confidence reading these
>letters from others pumpers!

First of all, most of us have "been there, done that". Hang in there, don't
throw in the towel yet, sounds like most things are working well for you
this first week ;-)

Several things to suggest re: the high BGs after set changes:

Karen suggested that the "stress" of changing the set can cause an increase
in your BG, so that is one possibility. Mary Jean suggested leaving the old
set in place for several hours after the new one has been inserted. Some of
us on the list do this and find it helps to stem the rise in BG after set
changes. Ted suggested that you make certain you bolus a small amount after
inserting the new set (usually around 1.0 unit) to fill the empty space in
the cannula if you are using SofSets or Silhouettes / Tenders / Comforts.
Metal needles don't require this bolus, incidentally.

If using a MiniMed pump and you are changing sets and reservoirs at the
same time, make certain that the pump driver arms are thoroughly seated
against the plunger arm. This can be done with a small bolus before
inserting the set (might need a 5.0 unit bolus).

If using a Disetronic pump and you are changing sets and cartridges at the
same time, make certain that the pump adapter cap is screwed in all the
way. Make certain that the piston rod is properly seated in the end of the
cartridge and everything seats properly in the cartridge chamber in the pump.

For all pumps, check that insulin drips from the end of the infusion tubing
when you prime it, prior to inserting or connecting. If the insulin drips
slowly, or not at all, repeat the prime. If things still don't seem right,
replace the tubing. I've had a number of times when I had what I call "slow
tubing" - it seemed to take forever for the drop of insulin to form at the
needle end. I switched to a new piece of tubing and things got better.

One other thought here. When I started pumping, I noticed that my mid
morning BGs were higher than expected, every other day. This pattern was
significant, because it corresponded to those days that I changed my set.

When I reviewed all my procedures, it became obvious that I was
disconnected for "too long" when changing sets, without taking a bolus to
compensate for the missed basal insulin. I would typically remove the old
set, shower, fill the new reservoir and insert the new set. When I first
started, there were times when this whole sequence took 30 - 45 minutes. I
have a *significant* dawn effect and this was simply too long to go without
my basal rate. 

The trick for me was to bolus a small amount prior to showering, so it
would carry me through the time I was disconnected. (Michael will probably
"chime in here" with his recommendation to leave the old set in place for a
time period corresponding to the length of time that your insulin is
active, 2-4 hours for Humalog, 4-6 hours for Velosulin or Regular). This
small bolus helped me greatly, flattening out the spike in my BG after the
set change. It also had the added benefit of reducing the "pressure" on me
when changing the set, because I knew that I had some insulin from the
bolus which was working while I was disconnected.

It often takes some detective work, but don't hesitate to look at each task
you perform to see if any small thing can be contributing to this rise.
Even though I log all my BG readings in a spreadsheet, my patterns of BG
rises after set changes didn't become *real* obvious until I used a colored
marker on the spreadsheet to mark readings over 200. It then became crystal
clear that these readings corresponded directly to set change days, usually
at the same time of day.

Bob Burnett

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