Bad Habits in Diabetes Care

Pump Infusion Set Change

The potential for infections at an infusion set site makes me nervous. I keep a prescription strength tube of bactroban around and use it if any site looks reddish, swollen, or even slightly weird. We also try to adhere to the three-day maximum for any one site. We set an alarm on the pump to remind of site changes, but sometimes my son forgets to tell us the alarm went off. Sometimes the site stays in for four days instead of three. When numbers start to creep up we're quick to change the site even if it's less than the prescribed three days. How bad is it to leave a site in for longer than three days?

Dr. C's response: Hopefully that last pump infusion set change was three days or less. For several reasons, this is an important principle to follow when using an insulin pump. Yes, there is a huge potential for infection around an infusion site (such as MSRA). I also prescribe bactroban to have available (use no more than two or three days) if the site has any evidence of more than the usual redness, swelling, or tenderness. In addition, as the infusion set is a foreign body, your tissues react and the site becomes dysfunctional with resultant higher blood sugars. If blood sugars start increasing, even if the site has been only 1-2 days, it is time to change. I also would recommend changing the infusion site during the day instead of in the evening so if it is problematic you will know sooner rather than waking up to high blood sugars and ketones in the morning.

IMPORTANCE: 10.

Guessing at Carb Counts

This is one area where we are already taking action. David Mendosa's recommendations on nutrition scales inspired our family to purchase the Salter scale. Using a scale and weighing the food has a profound effect on accuracy. Ball park guesstimates are okay when no scale is around but it is extremely useful to check yourself at least occasionally. Who knew that a slightly bigger apple was really 10 carbs more than my usual apple guess? Miscounting carbs has the greatest negative effect on my son's blood sugar. How often do you see inaccuracy in carb counting negatively affected blood sugar?

Dr. C's response: Every day. Effective carb counting is essential to successful control of blood sugars especially in basal bolus therapy, including injections (Lantus/Levemir and rapid acting insulin) and insulin pump therapy. In fact, at Children's National Medical Center, we are very hesitant to even consider insulin pump transition if our patients cannot carb count. Even if you know the carbohydrate amounts, it is essential to consider portion sizes. So, the carbohydrate amount for a small bagel is clearly not the same as for a large bagel. Good carb counters really can help themselves to improved blood sugar control.

IMPORTANCE 10

Bolusing After Eating

I suspect this one will have a bad affect on my son's next A1C. We always bolus before he eats and if he eats more than expected, we simply do another bolus. In the new middle school cafeteria we have no idea what he might eat. For safety's sake, the school nurse requested he check his blood sugar before lunch, then eat lunch, and then come to her office after he eats to tally up the carbs and bolus. Safe but not optimum. Bolusing before eating matches insulin to food better. How much of an effect does pre-dosing have on blood sugar numbers and the A1C?