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The infusion site should be checked at least once a day, and pump manufacturers recommend (hat (he infusion site be changed every 48 hours. Because erythema, pain, or irritation at the insertion site may indicate a local anatomical problem that could interfere with insulin delivery, they signal the need for an earlier change of the catheter. If this local irritation is a recurrent or chronic problem attributed to the tape, then a different tape can be used. Rarely, the patient's skin may be irritated by the catheter itself, in which case the "sandwich technique"—placing the catheter between two layers of tape, one on the skin and the other above the catheter to hold it in placc—is a suitable remedy. The catheter or infusion set is always inserted subcutaneously, and is inserted using aseptic technique after the skin has been cleansed with a solvent such as i.v. prep. The locations for insertion are wherever the patient feels comfortable; most patients choose the abdomen, sides, or back, but other locations are viable. Special circumstances may affect site selection. For example, in the last trimester of pregnancy, the abdomen, because of its enlargement and stretched skin, is avoided and the upper arms or other locations are chosen.

Tape is used to hold the infusion set in place to prevent hyperglycemia and possibly diabetic ketoacidosis as well as accidental removal. Many tapes are available for this purpose, and most manufacturers will supply a selection of tapes for first-time pumpers to try before deciding on the one best suited for their needs. Some patients have a problem with skin stickiness, most often due to perspiration; specially designed tape such as Skin-Tac or Mastisol liquid adhesive with Detachol to remove it may be useful.

When blood sugar levels are greater than 250 mg/dJ, it must be determined whether this state represents simple hyperglycemia or hyperglycemia with diabetic ketoacidosis before a decision can be made on the appropriate therapeutic course. The simplest way to make this determination is through the use of Ketos-tix, which change color in the presence of ketones in the urine. If no ketones are present, than the patient can take a correction bolus using the insulin pump and recheck his blood sugar level after 1 hour. If the blood glucose has not decreased, then the patient, according to (he instructions he should have been given, administers the correction bolus, via syringe and then attempts to determine why the pump-administered insulin was ineffective. The problem is found in greatest to least frequency from "the skin to the pump." The most common mechanical causes involve the catheter (e.g., removal, kinking, partial obstruction). Less often ^

die problem is a faulty connection of the cadieter to die pump, absence of insulin, |

failure of battery supply to the pump, or failure of the pump to deliver insulin °

because of pump damage. Nontechnological causes include inflammation at the insertion site and insulin decay resulting from physical or chemical alteration to 5

the insulin itself (usually from temperature alterations or incorrect handling). J

Prevention of diabetic ketoacidosis is a primary objective of the treatment jj of type I diabetes, whether the patient is on pump or syringe therapy. Special o

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