Continuous Subcutaneous Insulin Infusions Research Articles

Current Technologies for Managing Type 1 Diabetes Mellitus and Their Impact on Quality of Life-A Narrative Review.

Type 1 diabetes mellitus is a chronic autoimmune disease that affects millions of people and generates high healthcare costs due to frequent complications when inappropriately managed. Our paper aimed to review the latest technologies used in T1DM management for better glycemic control and their impact on daily life for people with diabetes. Continuous glucose monitoring systems provide a better understanding of daily glycemic variations for children and adults and can be easily used. These systems diminish diabetes distress and improve diabetes control by decreasing hypoglycemia. Continuous subcutaneous insulin infusions have proven their benefits in selected patients. There is a tendency to use more complex systems, such as hybrid closed-loop systems that can modulate insulin infusion based on glycemic readings and artificial intelligence-based algorithms. It can help people manage the burdens associated with T1DM management, such as fear of hypoglycemia, exercising, and long-term complications. The future is promising and aims to develop more complex ways of automated control of glycemic levels to diminish the distress of individuals living with diabetes.

Optimal Management of Insulin in Patients Undergoing 18F-Fluorodeoxyglucose Positron Emission Tomography Scans

ObjectiveThe management of insulin injections and insulin pumps before 18F-fluorodeoxyglucose-positron emission tomography integrated computerized tomography (FDG-PET/CT) scans is an important area to investigate given the rising rate of diabetes, the significant association between diabetes and cancer, and the complex relationship among glucose, insulin, and FDG tumor uptake. The purpose of this study was to determine the recommendations around subcutaneous insulin administration, insulin pumps, and hybrid closed-loop systems before FDG-PET scans. MethodsWe examined the websites of 100 hospitals selected from the 2022 US News and World Report top cancer hospitals for specific strategies around diabetes medication management before FDG-PET/CT scans. ResultsOf the 100 hospital websites, 61 had instructions addressing patients with diabetes. Of the 61 hospitals, 47.5% (n = 29) referred patients to their provider for further instructions, 18% (n = 11) referred patients to their own internal radiology department for further instructions, 16.4% (n = 10) had instructions on oral diabetic medications, 23% (n = 14) had instructions on insulin, and 3.3% (n = 2) had instructions on insulin pump management. Most commonly, instructions were to stop insulin 3 to 4 hours before the study and direct patients to their referring provider for more detailed instructions (n = 7). ConclusionThere is a lack of guidance and consensus among US cancer hospitals on managing insulin and continuous subcutaneous insulin infusions before FDG-PET/CT studies and a majority rely on referring providers to advise patients. However, society guidelines offer inconsistent recommendations and little research has been carried out to help guide referring providers. A multidisciplinary panel of specialists could help to guide practitioners on optimal management.

Identifying Those Patients with Type 2 Diabetes Who Might Benefit from Insulin Pump Therapy: Literature Review, Clinical Opportunities, Potential Benefits & Challenges.

Global prevalence and increasing incidence rates of type 2 diabetes (T2D) has rippling effects on healthcare costs and diminishing quality of life. Despite advances in technology, continuous subcutaneous insulin infusions (CSII), or insulin pump therapy, is rarely being recommended by health care professionals (HCP) and is underutilized in T2D management. This review analyzes the available literature for CSII use in T2D patients. Moreover, it discusses which groups of patients may benefit from CSII, potential challenges to CSII use, and suggests future directions for research to expand the applicability of this technology to the broader T2D population. This article is protected by copyright. All rights reserved.

Continuous Subcutaneous Insulin Infusions: Closing the Loop.

Continuous subcutaneous insulin infusions (CSIIs) and continuous glucose monitors (CGMs) have revolutionized the management of diabetes mellitus (DM). Over the last 2 decades the development of advanced, small, and user-friendly technology has progressed substantially, essentially closing the loop in the fasting and postabsorptive state, nearing the promise of an artificial pancreas (AP). The momentum was mostly driven by the diabetes community itself, to improve its health and quality of life. Literature regarding CSII and CGM was reviewed. Management of DM aims to regulate blood glucose to prevent long-term microvascular and macrovascular complications. CSIIs combined with CGMs provide an integrated system to maintain tight glycemic control in a safe and uninterrupted fashion, while minimizing hypoglycemic events. Recent advances have allowed to "closing of the loop" by better mimicking endogenous insulin secretion and glucose level regulation. Evidence supports sustained improvement in glycemic control with reduced episodes of hypoglycemia using these systems, while improving quality of life. Ongoing work in delivery algorithms with or without counterregulatory hormones will allow for further layers of regulation of the AP. Ongoing efforts to develop an AP have created effective tools to improve the management of DM. CSIIs and CGMs are useful in diverse populations ranging from children to older individuals, as well as in various clinical contexts. Individually and more so together, these have had a tremendous effect on the management of DM, while avoiding treatment fatigue. However, cost and accessibility are still a hindrance to its wider application.

Safety and effectiveness of do-it-yourself artificial pancreas system compared with continuous subcutaneous insulin infusions in combination with free style libre in people with type 1 diabetes.

The use of do-it-yourself artificial pancreas systems (DIYAPS) among people with type 1 diabetes is increasing. At present, it is unclear how DIYAPS compares with other technologies such as FreeStyle Libre (FSL) and continuous subcutaneous insulin infusion (CSII). The aim of this analysis is to compare safety, effectiveness and quality-of-life outcomes of DIYAPS use with the addition of FSL to CSII. Data from two large UK hospitals were extracted from the Association of British Clinical Diabetologists (ABCD) DIYAPS and FSL audits. Outcomes included HbA1c , glucose TBR (time-below-range), TIR (time-in-range), Diabetes Distress Score (DDS), and Gold hypoglycaemia score. Any adverse events were noted. Changes at follow-up were assessed using paired t-tests and ANOVA in Stata; TIR/TBR at follow-up assessed using unpaired t-tests; chi-square tests assessed the change in frequency of health utilisation (e.g. hospital admissions). DIYAPS (n=35) and FSL+CSII (n=149) users, with median follow-up duration of 1.4 (IQR 0.8-2.1) and 1.3 (IQR 0.7-1.8) years, respectively, were included. HbA1c with DIYAPS use changed by -10mmol/mol [0.9%] (p<0.001, 95% CI 5, 14 [0.5, 1.3%]) significantly lower (p<0.001) than in the FSL+CSII group -3mmol/mol [0.25%] (p<0.001, 95% CI 1, 4 [0.1, 0.4%]). TIR was higher and TBR was lower in the DIYAPS group. Adverse events were rare in both groups and no significant differences were observed in the frequency of healthcare utilisation. DIYAPS use was associated with a lower HbA1c levels, higher TIR and lower TBR compared with FSL+CSII. There was no significant increase in adverse events, although this should be interpreted cautiously given the low numbers of users. Full results from the ABCD DIYAPS audit are awaited.

Do pregnancy outcomes differ by mode of insulin delivery for type 1 diabetes mellitus?

Type 1 diabetes mellitus (T1DM) in pregnancy increases maternal and neonatal complications. These complications are related to degree of hyperglycemia and can be reduced with insulin treatment, via multiple daily injections (MDI) or continuous subcutaneous insulin infusions (CSII). CSII appears superior to MDI in non-pregnant patients, but it is unclear whether CSII confers clinical benefits in pregnancy. This study investigated whether mode of insulin delivery affects risk of complications among pregnant individuals with T1DM, in a contemporary cohort accounting for disease severity. All T1DM singleton pregnancies delivered at UCSF from 01/2008 to 07/2020 were included. The primary predictor was mode of insulin delivery, the primary maternal outcome was primary cesarean delivery (PCD), and the primary neonatal outcome was NICU admit. Baseline characteristics were compared using Fisher’s exact and Kruskall-Wallis tests. Odds ratios (OR) were obtained using a generalized estimating equations model to account for individuals with > 1 pregnancy during the study period. Early A1c and time since T1DM diagnosis were included in adjusted analyses as markers of disease severity. 129 individuals with 153 pregnancies were included, with 40% using MDI and 60% using CSII. There was no difference in PCD between the groups (51% CSII vs 49% MDI). CSII was associated with a significant reduction in the odds of NICU admit (57% vs 87%, p < 0.01), even after adjusting for early A1c, time since diagnosis, preterm birth, and year of delivery (adjusted OR 0.33, 95% CI 0.12-0.90). When used for T1DM in pregnancy, CSII reduced the odds of NICU admit by 67%. Currently, shared decision-making is utilized to determine best mode of insulin delivery, as there is no compelling evidence to promote use of one mode over the other in pregnancy. These findings provide preliminary support for improved neonatal outcomes with CSII and, if replicated in larger, multicenter cohorts, may encourage use of CSII over MDI.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Newest Diabetes-Related Technologies for Pediatric Type 1 Diabetes and Its Impact on Routine Care: a Narrative Synthesis of the Literature.

Purpose of ReviewThis review aims to address the actual state of the most advanced diabetes devices, as follows: continuous subcutaneous insulin infusions (CSII), continuous glucose monitoring systems (CGM), hybrid-closed loop (HCL) systems, and “Do-it-yourself” Artificial Pancreas Systems (DIYAPS) in children, adolescents, and young adults. This review has also the objective to assess the use of telemedicine for diabetes care across three different areas: education, social media, and daily care.Recent FindingsRecent advances in diabetes technology after integration of CSII with CGM have increased the popularity of this treatment modality in pediatric age and shifted the standard diabetes management in many countries. We found an impressive transition from the use of CSII and/or CGM only to integrative devices with automated delivery systems. Although much has changed over the past 5 years, including a pandemic period that precipitated a broader use of telemedicine in diabetes care, some advances in technology may still be an additional burden of care for providers, patients, and caregivers. The extent of a higher rate of “auto-mode” use in diabetes devices while using the HCL/DIYAPS is essential to reduce the burden of diabetes treatment.SummaryMore studies including higher-risk populations are needed, and efforts should be taken to ensure proper access to cost-effective advanced technology on diabetes care.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40124-021-00248-7.

Continuous Subcutaneous Insulin Infusions vs. Multiple Daily Injections of Insulin in Hospitalized Patients: Glycemic Trends in the First 24 Hours of Admission.

Continuous subcutaneous insulin infusion (CSII) is a common diabetes treatment modality. Glycemic outcomes of patients using CSII in the first 24 hours of hospitalization have not been well studied. This timeframe is of particular importance because insulin pump settings are programmed to achieve tight outpatient glycemic targets which could result in hypoglycemia when patients are hospitalized. This retrospective cohort study evaluated 216 hospitalized adult patients using CSII and 216 age-matched controls treated with multiple daily injections (MDI) of insulin. Patients using CSII did not make changes to pump settings in the first 24 hours of admission. Blood glucose (BG) values within the first 24 hours of admission were collected. The primary outcome was frequency of hypoglycemia (BG < 70 mg/dL). Secondary outcomes were frequency of severe hypoglycemia (BG < 40 mg/dL) and hyperglycemia (BG ≥ 180 mg/dL). There were significantly fewer events of hypoglycemia [incident rate ratio (IRR) 0.61, 95% confidence interval (CI) 0.42-0.88, p = 0.007] and hyperglycemia (IRR 0.79, 95% CI 0.65-0.96, p = 0.02) in the CSII group compared to the MDI group. There was a trend toward fewer events of severe hypoglycemia in the CSII group (IRR 0.15, 95% CI 0.02-0.93, p = 0.06). Patients using CSII experienced fewer events of both hypoglycemia and hyperglycemia in the first 24 hours of hospital admission than those treated with MDI. Our study demonstrates that CSII use is safe and effective for the treatment of diabetes within the first 24 hours of hospital admission.

Frequency of injection site assessment for lipohypertrophy in children and young people with type 1 diabetes.

Children and young people with diabetes are at high risk of developing lipohypertrophy (LH) as a result of daily injections of insulin. LH is characterised by dense nodules that are palpable beneath the skin's surface. A retrospective audit investigated the frequency of injection site assessment in children and young people attending a diabetes clinic over one year. The audit was conducted using the medical records of 76 eligible patients with type 1 diabetes, all treated with multiple daily injections or continuous subcutaneous insulin infusions for a minimum of six months from the audit start date. None of the participants had their injection sites assessed at every clinic visit. Just under one third ( n =23, 30%) received at least one injection site assessment within the audit year. Of these, 11 had LH detected. HbA 1c and average blood glucose levels were higher in those with LH, which was deemed significant. There was a slight increase in glucose variation in those with LH compared with those without LH. However, this result was not statistically significant. The frequency of injection site assessment is low in children and young people but the prevalence of LH is high. This means it is essential to improve healthcare professionals' injection technique education and assessment skills to minimise the risk of patients developing LH.

Experiences of Adults Using Continuous Subcutaneous Insulin Infusion: A Qualitative Study

Objectives: We aimed to determine the quality of life (QoL) of Kuwaiti adults with type 1 diabetes mellitus (T1DM) who used continuous subcutaneous insulin infusions (CSIIs) and to understand their perception of this treatment. Background: CSII is an effective and safe alternative to multiple daily injections for T1DM, with the potential to improve both glycemic control and QoL. Although CSII has been widely used in Kuwait, its effectiveness and benefits have not been properly evaluated. Healthcare providers and patients need more information on CSII before its initiation. Methods: In this qualitative case study, semi-structured individual interviews were performed using a topic guide. Interviews were stopped at data saturation point. Subsequently, a thematic analysis of transcripts was performed. Results: Eighteen adults with T1DM (8 males and 10 females; age 31.4 ± 6.4 years; diabetes duration 17.7 ± 9.5 years; CSII duration 3.6 ± 2.4 years) were recruited from the CSII clinic. Six main themes were studied: health benefits, lifestyle flexibility, improvement of mood and emotion, practical problems, physical and personal effects, and self-confidence to manage diabetes. CSII positively affected the QoL of participants’, most notably by enhancing lifestyle flexibility; however, important negative qualities were also reported. Conclusion: The identified themes highlight the complexity of the experiences of participants, and can be used to provide a framework to help healthcare providers understand how people with T1DM become aware of their treatment regimens. It is important to identify the positive aspects of CSII and not focus only on its negative effects.

Use of continuous subcutaneous insulin infusion (CSII) therapy in pediatric diabetes patients in the perioperative period.

Diabetes mellitus is one of the most common endocrinopathies encountered in the perioperative period, and the pediatric population is increasingly using continuous subcutaneous insulin infusions for diabetes management. As these patients present for procedures or surgery requiring anesthesia, the anesthesia provider is charged with the task of managing these pumps perioperatively. Here, we review our experience from a large tertiary care academic medical center and propose recommendations for the perioperative management of children and adolescents with diabetes who use insulin pumps.

Characteristics of young adults with multiple episodes of diabetic ketoacidosis.

Transition from paediatric to adult diabetes care can be associated with a deterioration in metabolic control and hospitalisation. This was a retrospective review (2012-2016) of medical records of all patients attending a transition diabetes clinic in a teaching hospital with paediatric and adult diabetes on the same site. Among the 91/102 (89.2%) patients with type 1 diabetes, mean age at first visit was 19 ± 2 years, last body mass index was 25.2 ± 4.7 kg/m2 , diabetes duration was 11 ± 6 years and 22 (24%) used continuous subcutaneous insulin infusions. Loss to follow-up was 15 (14.7%). Mental health issues were common (59%), as were prior pregnancies (23%) and diabetic ketoacidosis since diagnosis (39%). Those with diabetic ketoacidosis had a higher mean glycated haemoglobin (70 ± 19 vs 86 ± 25 mmol/mol or 8.6 ± 1.7 vs 10.0 ± 2.3%; P = 0.001), fewer clinic attendances (8 ± 5 vs 5 ± 4; P = 0.008) and fewer years in clinic (1.8 ± 1.7 vs 2.3 ± 1.4; P = 0.114). Our data suggest that investment in joint approaches with mental health services should be considered.

Evaluating the impact of an insulin pump discontinuation action plan on patient or caregiver confidence and anxiety.

Insulin pump failure and adverse events are common and therefore anticipatory education is recommended. Research in other chronic diseases shows written action plans improve confidence and adherence during an acute deterioration. However, no similar data exists for patients with type one diabetes mellitus provided with anticipatory education via an insulin pump action plan. This study evaluates whether an insulin pump action plan improves patient and caregiver confidence in managing a potential pump failure without a subsequent increase in anxiety. Adults with type one diabetes mellitus and caregivers of children with type 1 diabetes on continuous subcutaneous insulin infusions across four New Zealand diabetes services participated. Participants completed a questionnaire examining pump-related adverse events and self-reported confidence and anxiety in managing pump failure. An insulin pump action plan and focused education by their diabetes team was provided, with a follow-up questionnaire at least 3months later. 174/270 pump patients participated initially, with a follow-up response rate of 84.5% (147/174). Despite prior provision, many could not recall having an insulin pump action plan at study commencement (101/174, 58%), and of these 92% stated they would have liked one. Patients had good levels of confidence in the reliability of their pump and infusion sets/sites (Likert scores of 4.4/5 and 3.95/5) which was not undermined by the insulin pump action plan. Confidence in managing a potential pump failure showed a small but significant increase (3.66/5 to 3.95/5, p = 0.004) present in both adults and parents, with anxiety also showing a small increase (2.16/5 to 2.38/5, p = 0.012). Patient recall of prior insulin pump action plan education is poor, with the vast majority of patients interested in further written anticipatory education regarding potential pump failure. The provision of an insulin pump action plan increases self-reported confidence in managing unexpected pump failure with a small associated increase in anxiety.

Clinical diagnosis for dusk phenomenon of diabetes.

The diabetes dusk phenomenon (spontaneous and transient pre-dinner hyperglycemia) anecdotally exists but has not been investigated.A total of 80 diabetic patients that received continuous subcutaneous insulin infusions were retrospectively studied. They were grouped into a routine group (R) (consecutive δDG [dusk blood glucose difference] <0 mmol/L) and a classic dusk phenomenon group (CDP, consecutive δDG≥0 mmol/L). δDG represents differences in blood glucose measurements between pre-dinner and post-lunch (δDG: dusk blood glucose difference). Other patients were placed in a suspicious group (S). The suspicious group was further divided into 3 groups based on the frequency at which the δDG occurred: suspicious 1 group (S1), δDG≥0 mmol/L occurred once only; suspicious 3 group (S3), δDG < 0 mmol/L occurred once only, and the remaining patients were grouped in the suspicious 2 group (S2).We identified the CDP and S3 groups as the "clinical dusk phenomenon" group (CLDP). We confirmed that the S1 and R groups to be in the "clinical routine" group. The S2 group was significantly different from the CDP group. In addition, the S2 group had significant differences in δDG measurements and post-lunch blood glucose values compared with the R group, but no differences in other parameters were seen. Multiple comparisons with the other suspicious groups also showed no statistical difference in many parameters. Thus, we placed these patients into the "suspicious clinical dusk phenomenon" group (SDP). The δDG cut-off for the CLDP group was 1.0167 mmol/L. The pre-dinner-pre-lunch blood glucose cut-off for this group was 2.72 mmol/L. The δDG cut-off for the SDP group was -0.95 mmol/L. The pre-dinner-pre-lunch blood glucose cut-off for this group was 0.87 mmol/L. The cut-off points for the post-dinner-post-lunch blood glucose measurements in the CLDP and SDP groups were both 1.2667 mmol/L.A consecutive δDG≥0 or a once only δDG < 0 could be diagnosed as falling into the CLDP group. The CLDP could be excluded when a consecutive δDG < 0 or a once only δDG≥0 was found. Patients falling into other categories were placed into the SDP group.

CGM Shows Islet Transplantation Prevents Hypoglycemia, Correcting Time in Range and Reducing Glycemic Variability, Despite Subnormal Beta-Cell Function

The impact of clinical islet transplant (CIT) on glycemic variability compared with type 1 diabetes (T1D) subjects and nondiabetic controls has not been explored. Aim: To evaluate the relationship between glycemic variability (by CGM) and islet graft function in CIT vs. T1D subjects on Continuous Subcutaneous Insulin Infusions (CSII), using healthy, nondiabetic subjects as reference. Methods: CIT recipients n=39, (insulin independent vs. dependent: n=15 vs. n=24) and subjects on CSII therapy (n=10) all with T1D were assessed at 1 year post-intervention with CGM. Published data from nondiabetic controls were used for comparison. Fasting glucose, C-peptide and HbA1c concentrations and insulin dose were recorded (including in a control cohort, n=28) where applicable; BETA-2 scores were calculated in those with endogenous C-peptide. Results: CIT recipients had decreased coefficient variation of glucose and lower time in hypoglycemia vs. those on CSII therapy; BETA-2 scores were ∼20% lower in CIT recipients vs. controls (p&amp;lt;0.05). Conclusion: Islet transplant recipients have diminished glycemic variability with abrogation of hypoglycemia vs. CSII at 1 year. Normalisation of time in range and glycemic variability was observed in insulin independent CIT recipients despite beta cell function ∼20% lower than in nondiabetic subjects. Disclosure S. Forbes: None. T. Olateju: None. A. Lam: None. J. Casey: None. J. Campbell: None. L. Reid: None. R.A. Oram: Other Relationship; Self; Randox. A.J. Malcolm: None. A. Shapiro: Consultant; Self; Viacyte, Inc., Protokinetix. P.A. Senior: Consultant; Self; Abbott, AstraZeneca. Research Support; Self; AstraZeneca, Prometic Life Sciences Inc., Novo Nordisk Inc., Sanofi. Consultant; Self; Eli Lilly and Company. Speaker's Bureau; Self; Eli Lilly and Company, Novo Nordisk Inc.. Consultant; Self; Novo Nordisk Inc., Janssen Pharmaceuticals, Inc.. Speaker's Bureau; Self; Janssen Pharmaceuticals, Inc.. Consultant; Self; Boehringer Ingelheim Pharmaceuticals, Inc.. Speaker's Bureau; Self; AstraZeneca, Merck &amp; Co., Inc., Abbott. Research Support; Self; Viacyte, Inc..

S131. Reducing glucose variability with continuous subcutaneous insulin infusion is associated with reversal of axonal dysfunction in type 1 diabetes mellitus

Introduction Strict glycaemic control has been shown to reduce the risk of developing peripheral neuropathy in patients with type 1 diabetes mellitus (T1DM). Continuous subcutaneous insulin infusions (CSII) can provide improved diabetes control by reducing both mean glucose and glucose variability (GV). This could potentially reverse functional changes in neuronal membrane ion channels and pumps that occur prior to the onset of permanent nerve damage, and thus prevent the fatal cascade that leads to axonal death. Methods 12 patients with T1DM treated with multiple daily insulin injections (MDII) were assessed with nerve excitability testing prior to, and three months following initiation of CSII. Blood glucose, HbA1c and GV measured using a continuous glucose monitor (CGM) were correlated with changes in nerve excitability parameters. Results Overall, simply commencing treatment with CSII for three months did not significantly alter any nerve excitability parameter or GV, although HbA1c improved. In four patients, some deterioration in GV was observed, whilst eight patients had improvement in standard deviation (SD) and mean amplitude of glycaemic excursions (MAGE). For these eight patients, there was normalisation of depolarising and hyperpolarising threshold electrotonus and recovery cycle superexcitablity. Standard deviation of CGM readings correlated with all these parameters. Conclusion The initiation of CSII in patients with T1DM does not ensure a neuroprotective effect in itself, but when it is successful in reducing GV, there is reversal of axonal dysfunction. The pattern of nerve excitability improvement seen is most consistent with restoration of transaxonal membrane potential due to normalisation of Na+/K+ pump function.

Fifteen-minute consultation: Insulin pumps for type 1 diabetes in children and young people

There is increasing worldwide use of continuous subcutaneous insulin infusions in paediatric type 1 diabetes (T1D), reflecting recent research outcomes and guidance, as well as families’ wishes. Children/young people may...

Diabetes Educators' Intended and Reported Use of Common Diabetes-Related Technologies: Discrepancies and Dissonance.

Technology provides adjuvant and/or alternative approaches to care and may promote self-care, communication, and engagement with health care services. Common recent technologies for diabetes include continuous subcutaneous insulin infusions (insulin pumps), continuous glucose monitoring systems, smartphone and tablet applications, and telehealth (video conferencing). This study reports Australian diabetes educators' intentions and reported professional use of these technologies for people with type 1 diabetes, and factors predictive of this. An anonymous, web-based questionnaire based on the technology acceptance model was distributed to members of the Australian Diabetes Educators Association through their electronic newsletter. Exploratory factor analysis revealed a 5-factor solution comprising confidence and competence, improving clinical practice, preparation (intentions and training), ease of use, and subjective norms. Logistic regression analyses identified factors predicting intention and use of technology. Respondents (n = 228) had high intentions to use technology. The majority reported using continuous subcutaneous insulin infusions, continuous glucose monitoring systems, and applications with patients, but usage was occasional. Confidence and competence independently predicted both intentions and use of all 4 technologies. Preparation (intentions and training) independently predicted use of each technology also. Discrepancies and dissonance appear between diabetes educators' intentions and behavior (intentions to use and reported technology use). Intentions were higher than current use, which was relatively low and not likely to provide significant support to people with type 1 diabetes for disease management, communication, and engagement with health care services. Continuing education and experiential learning may be key in supporting diabetes educators to align their intentions with their practice.

Safety and Efficacy of a Peri-Operative Protocol for Patients with Diabetes Treated with Continuous Subcutaneous Insulin Infusion who are Admitted for Same-Day Surgery

The number of people with diabetes using continuous subcutaneous insulin infusions (CSII) with an insulin pump has risen dramatically, creating new challenges when these patients are admitted to the hospital for surgical or other procedures. There is limited literature guiding CSII use during surgical procedures. The study was carried out in a large, urban, tertiary care hospital. We enrolled 49 patients using insulin pump therapy presenting for 57 elective surgeries. We developed a CSII peri-operative glycemic management protocol (PGMP) to standardize insulin pump management in patients admitted to a same-day surgery unit (SDSU). The purpose was evaluate the safety (% capillary blood glucose (CBG) <70 mg/dL and/or pump incidents) and efficacy (first postoperative CBG ≤200 mg/dL) of the CSII PGMP. We determine the contribution of admission CBG, type of anesthesia, surgery length, and peri-operative steroid use on postoperative glycemic control. Overall, 63% of patients treated according to the CSII PGMP had a first postoperative CBG ≤200 mg/dL. There were no episodes of intra- or postoperative hypoglycemia. For patients treated with the CSII PGMP, the mean postoperative CBG was lower in patients with anticipated or actual surgical length ≤120 minutes (158.1 ± 53.9 vs. 216 ± 77.7 mg/dL, P<.01). No differences were observed with admission CBG, type of anesthesia, or steroid use. This study demonstrates that a CSII PGMP is both safe and effective for patients admitted for elective surgical procedures and provides an example of a standardized protocol for use in clinical practice.

Management of a patient with diabetic ketoacidosis in the emergency department.

Diabetic ketoacidosis is a common problem among known and newly diagnosed diabetic children and adolescents for which they will often seek care in the emergency department (ED). Technological advances are leading to changes in outpatient management of diabetes. The ED physician needs to be aware of the new technologies in the care of diabetic children and comfortable managing patients using continuous subcutaneous insulin infusions. This article reviews the ED management of diabetic ketoacidosis and its associated complications, as well as the specific recommendations in caring for patients using the continuous subcutaneous insulin infusion, serum ketone monitoring, and continuous glucose monitoring.