Insulin infusion device complication

Background

• Commonly used by patients with type 1 diabetes in the US
• External device connected by flexible tubing to a subcutaneous catheter
• Delivers continuous basal insulin and (by manually activating) bolus insulin (prandial or correction doses)
• Patient switches subcutaneous site every 3 days, refills insulin reservoir as needed every few days

Complications

• Hyperglycemia/DKA
  • Due to failure to deliver insulin
  • accidental (or iatrogenic) disconnection, kinked tubing, empty reservoir, uncharged batteries, poorly positioned needle, lipohypertrophy, patient not rotating sites
  • DKA can occur very rapidly if pump fails, since pumps only use rapid-acting insulin
• Hypoglycemia
• Local complications
  • Cellulitis, usually due to strep or staph
  • Local reactions to adhesives or insulin preparation
  • Lipohypertrophy
    • Subcutaneous granulation tissue due to local insulin action
    • May look/feel like an abscess
    • Area has decreased sensation
    • Infusing through such sites→ erratic insulin absorption→ labile blood glucose, hyperglycemia

Evaluation

• See Hyperglycemia and DKA
• See Hypoglycemia
• See Cellulitis
• Patients most often know how to operate and perform basic diagnostics on their pump
• Many devices have a log of bolus histories and changes to basal rates, alarms, etc.
• All major pump manufacturers have a 24/7 technical support hotline

Management

• Awake, alert patients without diabetes-related complaints should be allowed to operate their pump while in the ED
• If pump needs to be disconnected for >1hr, give a dose of subcutaneous insulin
• Hypoglycemia
  • Do NOT disconnect pump
  • Work up and treat as you would any other hypoglycemic patient
• Hyperglycemia
  • Have patient administer an insulin bolus
• DKA
  • Assume device failure
  • Turn off and disconnect pump by pulling the catheter out from under the dressing removing it from the subcutaneous insertion site
  • Continue usual DKA management

See Also

• Medical device complications
• Insulin
• DKA, Hyperglycemia
• Hypoglycemia

References

Authors

Claire, Ross Donaldson, Daniel Ostermayer, Neil Young, Michael Holtz