Pump Initiation Settings - Medtronic Diabetes Canada

1 Meal Bolus: 1 Unit of insulin covers this many grams of carbohydrate. Carb Ratio: (B)_____ (L) _____ (D) _____Insulin Sensitivity Factor: 1 Unit of insulin lowers BG _____ mmol/L(Current BG Target) Sensitivity Factor = Correction DoseBG Target Range: Daytime = _____mmol/L _____mmol/LBG Target Range: Nighttime = _____mmol/L _____mmol/L_____ x units = _____ units/dayFax to:Patient Name: DOB: Current Daily Injection Dose: unitsPump Model:Pump Serial Number.

2 Pump Initiation Settingsprescriber s instructions to patientCalculations for Starting DosesReduced Injection Dose_____ units/day x = _____ units/day_____ x units = _____ units/day_____ grams _____ units/day = _____ grams/unit100 _____ units = _____mmol/L/1 unit(_____ units/day + _____ units/day) 2 = _____ units/day_____ units/day x _____ = _____ units/day_____ units 24 hours = _____ units/hourWeight DosePump Total Daily DoseTotal Daily Basal UnitsInitial Basal RateInsulin-to-Carb RatioInsulin Sensitivity Factor Time Rate1) _____ @ _____2) _____ @ _____3) _____ @ _____4) _____ @ _____5) _____ @ _____Insulin-to-Carb Ratio Time Ratio1) _____ _____2) _____ _____3)

3 _____ _____Insulin Sensitivity Factor_____ mmol/L /unitActive insulin Time_____ hoursClinical Considerations* Day NightAdults and Adolescents (13+ yrs): mmol/L mmol/LSchool Age (6 12 yrs): mmol/L mmol/LToddler to Pre-school (0 6 yrs): mmol/L mmol/LHypoglycemia Unawareness: mmol/L mmol/LPregnancy: mmol/L mmol/LBG Target RangesDay_____ mmol/L _____mmol/LNight_____ mmol/L _____mmol/LPump TDDB asal RateISF Initial Pump Start SettingsAdjustment Instructions for Patients* If night, fasting/pre-meal or bedtime BG below target, decrease basal 10 20% If night, fasting/pre-meal or bedtime BG above target, increase basal 10 20% If post-meal BG less than above pre-meal BG, increase carb ratio by 10 20% If post-meal BG more than above pre-meal BG.

4 Decrease carb ratio by 10 20%Elevated BG: Verify trends 2 3 days before adjusting Low BG: Consider immediate adjustmentComments:Prescriber Name: Signature: Date:Call MD for severe low BG or ketones. Call Medtronic for technical issues at 800-646-4633. *Pumping Protocol by B Bode, et 20130530 2013 Medtronic MiniMed, Inc. All rights Dose Pump TDDW eight DosePump TDDR educed DoseWeight DoseTotal Daliy BasalTotal Daily BolusPump TDD% BasalInitial Basal RateInsulin-to-Carb RatioInsulin Sensitivity FactorMake adjustments if BG is outside of these ranges:Fasting/pre-meal: _____ to _____ mmol/LPost-meal: _____ to _____ mmol/LBedtime: _____ to _____ mmol/LNocturnal: _____ to _____ mmol/L12 instructions are valid for 6 months unless otherwise specified here.

5 Daily BasalDaily Injection DoseWeight (lbs)Daily Carbs500 _____ units/day = _____ grams/unitInsulin-to-Carb RatioTotal Daily Bolus Units_____ units/day - _____ units/day = _____ units/dayOR Pump TDDT otal Daliy BolusTotal Daily BasalPump TDDMax Basal Rate: _____ unitsMax Bolus: _____ unitsBasal RatesBolus Wizard SettingsClinical Considerations*Adults:4 5 hoursChildren:3 4 hoursPregnancy: 3 4 hoursWeight (kgs)Weight DoseOR12 Weight: Date: lb/kgICR+=Pre-pump Blood Glucose Log SheetPatient: _____ DOB: _____Phone: (Home) _____ (Work)_____ /_____ Time RateBasal Rate: 1.

6 12 _____Date _____ /_____ /_____12 GlucoseCarb GramsFood DoseCorrection DoseTotal BolusDate _____ /_____ /_____12 GlucoseCarb GramsFood DoseCorrection DoseTotal BolusDate _____ /_____ /_____12 GlucoseCarb GramsFood DoseCorrection DoseTotal BolusDate _____ /_____ /_____12 GlucoseCarb GramsFood DoseCorrection DoseTotal BolusDate _____ /_____ /_____12 GlucoseCarb GramsFood DoseCorrection DoseTotal BolusNotes:Pumping Protocol by Bruce Bode, MD. 2008 Medtronic MiniMed, Inc.

7 All rights reserved. 9402236-011 042408 Meal Bolus: 1 Unit of insulin covers this many grams of carbohydrate. Carb Ratio: (B)_____ (L) _____ (D) _____Insulin Sensitivity Factor: 1 Unit of insulin lowers BG _____ mmol/L(Current BG Target) Sensitivity Factor = Correction DoseBG Target Range: Daytime = _____mmol/L _____mmol/LBG Target Range: Nighttime = _____mmol/L _____mmol/LFax to: _____