Continuous subcutaneous insulin infusion (CSII)

Mimics the function of the normal pancreas by continuously delivering insulin into the subcutaneous tissue.

Allow more flexibility in food, improves quality of life and improves physical activity in type I diabetics.

8% of type I diabetics in the U.S. use CSII.

Insulin pumps have memory, multiple basal rates, bolus options, lockout features and remote control features.

Requires glucose monitoring at least four times daily, before meals and at bedtime.

Consists of a pump, an infusion set and a syringe filled with rapid acting insulin.

Infusion site is changed every two to three days.

Associated with a better patient satisfaction and diabetes control.

Infusion utilizes a pump to administer rapid acting insulin at a slow basal rate, 24 hours a day through a fine manual and planted in the subcutaneous tissue, with patient activated insulin boosts at meal times.

Basal rates of rapid acting insulin is usually 0.5-1.5 U/h.

The basal rate can be changed to increase or decrease the insulin flow.

The basal rate can be altered on demand or preset to change at any time, and an onboard bolus calculator advises regarding in dosage at meal times estimated on the base of a carbohydrate intake, a free meal and target blood glucose levels, insulin sensitivity and calculation of the insulin remaining since the previous bolus.

The insulin pump can be activated to deliver bolus doses of insulin when the patient gets ready to eat, allowing flexibility in meal time and amount of calories eaten.

Bolus insulin is rapid acting type and the dose is determined in part by utilizing the carbohydrate-to-insulin ratio.

More sophisticated insulin pumps have square bolus and dual wave bolus features and can calculate bolus dose to control high fat and high protein meals.

Determining factors for bolus dosing include blood glucose level, carbohydrate-to-insulin ratio, target glucose level, grams of carbohydrates in planned meal and insulin sensitivity.

Control is best attained by a combination of basal insulin rate adjustment and bolus doses of insulin.

Major indication for insulin pump management is the failure of multiple daily insulin injection treatment to control glucose levels.

Indications for use include: elevated HbA1c, recurrent diabetic ketoacidosis events, frequent episodes of hypoglycemia, low insulin requirement, need for a flexible insulin administration schedule, presence of diabetic complications, Dawn phenomenon, pregnancy, following renal transplantation, unstable diabetic control with multiple insulin injections and patient desire.

Before initiation of pump infusion the basal and bolus doses of insulin need to be established based on prepump glucose levels.

Basal rate may need to be altered during the day as insulin needs are altered by lifestyle factors and the dawn phenomenon.

Dawn phenomenon refers to increased hormone production antagonizing insulin action and occurs between 2 and 8 am.

Insulin pump therapy improves glycemic control in type 1 diabetic patients because it can reduce the within-day and between-day glycemic variability with insulin injections.

The US Food and Drug Administration has approved Medtronic’s MiniMed 670G hybrid closed looped system, intended to automatically monitor glucose and administer basal insulin doses in individuals aged 14 and older with type 1 diabetes.

The device, also ref2242ed to as an “artificial pancreas,” adjusts insulin levels with little-to-no input from the user.

It measures glucose levels once every 5 minutes and administering or withholding insulin dependent upon these readings.

It includes an insulin-measuring sensor, an insulin pump, and an infusion patch with a catheter for insulin delivery.

Continuous subcutaneous insulin fusion therapy should be considered in patients who experience recurring episodes of severe hypoglycemia.

Risks associated with use of the device include hypoglycemia, hyperglycemia, and skin irritation.

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