Diabetes Self-Management Blog

For those of you who don’t use an insulin pump and who are not familiar with the nuances of pumping insulin, some of the content of this week’s blog entry may either be cryptic or irrelevant, or both. My hope is that a nonpumping and unfamiliar-with-insulin-pump audience will be able to get the gist, however. So, without further ado…

Beware the infusion site that appears to be happily stuck to your skin following a bump or tug or some other outside impact on said site. For all outward appearances, it may seem perfectly fine. But heed my experience for the cannula tweak.

Confused? Okay, here’s what happened. Sunday for dinner we had a delicious angel hair pasta with tomatoes and basil and Feta cheese. I bolused for the meal, ensuring that I had more than enough insulin to cover the carbs in a meal such as this. We’re talking a 7 PM dinner, and so by the time I checked again two hours later, I was somewhat surprised to find that my blood glucose was high.

However, because after two hours I still had insulin on board (I have a three-hour duration-of-insulin action), I didn’t issue a correction bolus for a blood glucose in the low 200s.

I decided to check my blood glucose again before I went to bed at 11 PM, and this time it was in the low 300s. What the heck? I examined my insulin pump to ensure that the bolus for dinner had been completed (it had); I looked at the tubing to make sure nothing was wrong (it wasn’t); and I looked closely at the infusion site on my stomach to verify that the site itself was in place and nothing looked amiss (nothing looked amiss).

So what was going on?

I figured that perhaps I had bolused erroneously; there were a lot of cherry tomatoes in the meal, and maybe I didn’t pay enough attention to their carbs. But to be more than 200 mg/dl above my target blood glucose level? Something wasn’t right.

I issued a correction bolus and decided I would stay up a few more hours and check at 1 AM. (I had no difficulty remaining awake because I was addicted to watching pundits talk about the presidential election.) At 1 AM, I checked again. Still in the 300s. Unphased by the high numbers, or rather, not panicking because things like this no longer cause me too much grief, I decided to do a complete change of insulin-pump supplies: new insulin, new reservoir, new surgical tubing—new infusion site, in short.

When I removed the old infusion site from my stomach and examined it, I noticed that the cannula was bent and lying flat against the hard plastic backing of the site. And on my stomach I noticed an irritated few-millimeter valley indention where the cannula had been lying flat and pushing against my skin. There had been no subcutaneous cannula since around noon on Sunday!

And why was that? How had the cannula become dislodged without the infusion site adhesive coming undone?

I’m pretty sure that what had happened was that at noon, when I was carrying my laptop upstairs, I dislodged the cannula inadvertently. Let it be known that I’d been doing yard work not 30 minutes earlier, so I didn’t have my insulin pump attached (the site was there, but it wasn’t “completed” by the tubing’s attachment, which rounds off and smoothes out the site; when the surgical tubing isn’t attached, the nub upon which the tubing attaches protrudes and has a greater chance of catching on something).

I guess that I “popped” the cannula out when the laptop grabbed the infusion site momentarily as I shifted it from one hip to the other. I felt the laptop catch on the site, but when I checked to see if the adhesive had become unstuck and found that it hadn’t, I thought that everything was just fine.

Instead, what had happened was that the center of the site rose quickly, imperceptibly to me, and with it the cannula. However, the cannula didn’t drop back into my body; instead, it buckled and folded under the site. For the remainder of the day, through basal and bolus, the insulin pooled under the site and was never administered into my body.

The mystery of the high blood glucose numbers had been solved.

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Comments
  1. Dear Eric. I know that I may sound like a Luddite but does this extra hassle and much more money result in much better blood sugar control? I know that using a pen injector for the bolus and syringe for the long acting results in unusual action and you wonder how much insulin leaks out the more so when you inject just 2 IU. This would be a problem that is eliminated with the pump. There may also be an advantage in using only a fast acting insulin with more predictable kinetics. Are there any scientific studies that show how much better pumps are?

    Congratulations on Obama’s win. I did not think I would live long enough to see this but I still remember that black people had to use a separate water fountain in certain parts of the US. This was at the height of the cold war and a communist country I visited then did not have this feature. Good job guys.

    Posted by CalgaryDiabetic |
  2. Dear Calgary,

    For me the money thing is thankfully covered by insurance. As for better blood-sugar control, I never did pen injections long enough to be able to answer that from personal experience (I went on an insulin pump three mos. after diagnosis), but I would assume that if other people chimed in, they’d probably say that, yes, pumping does provide better bg control–or, rather, it allows you greater freedom from making sure you eat at the same time and having to administer basal injections at the same time, while still achieving good bg control. I’m sure that all of this “better control” stuff is specific to the type of person managing the diabetes: I’m sure there are lazy insulin pumpers with horrible control; while I’m certain there are people using decades-old technology who are still holding onto A1Cs in the low 6s.

    Do I know of scientific studies right off the top of my head? No. Anyone else out there have any good reading?

    And thanks on thinking of us down here w/the Obama win. I heard a pretty nifty commentary by Michigan Radio sports commentator John U. Bacon on my drive into work this morning. It’d be a long URL, so here’s the tiny: http://tinyurl.com/5vr4s4

    Thanks for reading my blog!

    Eric

    Posted by Eric |
  3. I have had this happened to me lots of times. Here I continued to give myself insulin and to no prevail I never got any of the insulin that I had been Bolusing for.

    Do you know much about the Real TIme System?
    The sensor devices?

    If so please e-mail me your knowledge. Thanks,

    Posted by broop |
  4. I was on MDI (multiple daily injetions) for 8 months before going on a smart pump (they are all smart pumps these days)and I can state categorically that the pump wins hands down. There is no real downside, this side of diabetes. My TDD (total daily dose - both basal and bolus) was about 36 units. It went down to 24-28 units on the pump. My A1C went from a personal best of 7.3 on MDI to the low 6’s. Yes, I could have gotten my MDI A1C down lower, but I would have had to spend more time on management and there were many times when I was way too active for that to be practicable. Spikes are not as high — 180 is a really high number for me now, whereas I was happy with numbers under 230 after eating before. I am almost able to eat much more normally, exercise harder, and get on with my life better on the pump. The insertions leave no bruise or scars or marks and have been completely painless. Best of all, I am becoming successful at regulating my body and my lifestyle toward normal standards. I say “toward”. It is all relative and a pump does not make diabetes go away or completely eliminate the metabolic hit the disease makes, but it is the best therapy out there currently. We are all worth the best care.

    Posted by Peter Mead |
  5. I have dislodged my cannula on numerous occasions. There are several reasons; I am active in non aerobic outdoor activities, I work in a lab on computer chips in heavy machinery, I wear cargo pants in my off hours (with the pump in the side pocket), my sons play rough, etc.

    As a result, I do two things that help. First, I use heavy duty surgical tape to set a loop in my cannula taped to my stomach. That way if the cannula gets snagged, the loop will pull out before the infusion site has any stress. And second, I inspect my infusion site twice a day in a mirror. If the white adhesive around the connector is discolored in any way (insulin will turn it off white) I replace the site.

    There are many advantages to using a pump, but it requires constant attention. One thing is for sure, trust you glucose meter. If you have a high reading three hours after a bolus, there is a good probability that there is a failure somewhere in the system. You did everything you could in this case. I would suggest this… use a pen or syringe rather than a bolus right before bed. If the system is preventing you from getting your insulin, you will wake up to a reading somewhere between 120 and 150, and you can safely change out the system. If the system is working you will wake up to a normal reading. Good luck!

    Posted by Rob in MTown |
  6. I TOO HAVE FREQUENT PROBLEMS WITH INSULIN NOT BEING DELIVERED BECAUSE OF PROBLEMS WITH INCORRECT INSERTION OF CANNULA.JUST TODAY I WOKE UP WITH 250 BLOOD SUGAR READING. AFTER SEVERAL READINGS AND CORRECTION BOLUSES OVER THRTEE HOURS READING WAS 225. MY AVEAGE READINGS IN THE MORNING ARE 100-125.I CHANGED CANNULA AND SITE AND 2 HOURS LATER READING WAS STILL 200. TRIED CORRECTION BOLUS BUT TWO HOURS LATER READING STILL 200. CHANGED CANNULA AGAIN AND SEVERAL HOURS LATER READINGS WERE BACK TO NORMAL.THE FIRST TIME CANNULA WAS BENT FLAT BUT SECOND TIME NO PROBLEMS WERE SEEN . HOWEVER WHEN I REMOVED 2ND CANNULA SITE BLED QUITE A BIT. I LOVE MY PUMP INSPITE OF THESE PROBLEMS AND MY LATEST A1C WAS 6.2.

    Posted by jack |
  7. Hi Eric,
    For most pump users I think we can say “been there and done that.” I had the cannula come out of the skin the first time when the pump fell off my belt and jerked the tubing connected to the infusion site pulling the 6 mm cannula right out. Of course I didn’t realize it until a couple of hours later when I did a pre lunch blood sugar and it was close to 300. I did a correction bolus drank several glasses of water and waited an hour to do test #2. Now it was over 300. I got out my backup insulin pen and did a partial correction bolus and waited another hour to do test #3. Now my blood sugar was just slightly under 300 and starting to come down. I then decided to change the infusion set(INSET)and when I removed the old site I saw exactly what you described,the cannula was bent over pressing against the surface of the skin. With the new site in place,another correction bolus,and tests #4 & #5 my blood sugar was back to normal just in time for cocktail hour :)

    Florian (T1,41yrs)
    Animas 2020 + Novolog

    Posted by Florian |
  8. This has happened to me a couple of times. Caught the insertion set on the edge of a shelf at the grocery store when stretching on my tiptoes to get something on the top shelf. I quickly lifted up my shirt, after checking both ways in the aisle, and it looked fine, but I was wrong, and also kept correcting my blood sugar, only to find it was approaching 300. Another time I caught it on the towel after showering.

    Posted by pldarman@yahoo.com |

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