Our latest experience of a pump site going bad on day 3

Tips, Tech & Gear Pump
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Our last 36 hours were very frustrating due to a site going bad on day three—except that we did not recognize it as such.

The primary symptom was that basal needs suddenly increased, over a few hours, from -15% (where they had been for a week), to +20% (which is typical of upcoming sickness).

This basal change, of course, came with quite a bit of trouble, because, for us, adjusting to basal change takes typically 8-12 hours during which our control is often poor. In this case, it was very poor.

After the first twelve hours, we had adjusted to the new basal level, when we started getting violent peaks and valleys without a clear cause. Unfortunately, for a teenager in puberty, this phenomenon is not unknown–it is actually rather frequent (at least for a peak). After a few hours of this regimen, we started suspecting a site problem. We were getting close to the 72 hour period for this pump site (Omnipod), so we were due for a change, but stupidly we kept it on for a few hours longer (we often keep a pod going for another 4-8 hours for schedule convenience).

This delay led us into a very long 300 peak that took large amounts of insulin, much more than the correction factors would indicate (about 14 units over 6 hours). We changed the pod when the peak was finally going down.

The interesting part of it is that, after the new pod was in place, taking care of the insulin tail for this peak was an absolute bear. Our insulin tail is normally 5.5 hours (although, naturally, when you have injected 15 or 20 units for a peak we see a longer tail). But, in this case, we were still having to deal with delayed insulin absorption 10 hours after the insulin had been injected.

Not being sure of where we really were in basal after all that trouble, we had another few hours blundering along for a new basal level after having changed our pod, which resulted in a second (but easier) peak of long duration. It is only when injecting for that peak that we were able to prove to our satisfaction that the new pod was getting a timely response to an injection, thereby proving that the old pod had been the problem all along.

But this cost us 28-30 hours of terrible control with the old pod, plus another 8 hours with the new pod, and a whole night of staying up (at one time, we were hand testing every 5 minutes because we were chomping large quantities of fast carbs every 10 minutes and still going down dangerously low). After all was said and done, we are now back to the basal level that we started with.

I am looking back and wondering how we could have spotted this earlier and avoided this pattern altogether. The problems:

  • the corrections still worked, just not very well
  • the basal still worked, just not very well
  • sickness creates the same elevated basal pattern, as well as the same insulin insensitivity in corrections
  • until 8 hours into the new pod, there was no absolute proof that the old site was progressively failing

What is the rule you use to diagnose a site going bad? Until now, I have used a somewhat similar rule to @Jen 's (two failed corrections on a row and one pen correction working), but this did not work out well here.

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You could ask to have the prescription written for a 2-day change and just always swap it after 2 days. There is a little more maintenance required, but it would probably improve your consistency.

If you document the issue, your endo should go along with it. It doesn’t require any kind of re-approval, it’s simply a prescription written for a different amount.

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@Michel, we had so many problems on day three of our pump sites, that we had our prescription changed to a 2-day change out. It has helped tremendously.

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The prescription for our infusion sites is 2-1/2 days per.

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@Michel, you are one of my best basal buddies on here! So sorry you guys had to slug through that nightmare.

Can you describe the first high a bit more? How long did it take for him to get to 300 and how long was he up there? Did he level at 300 and stop climbing?

The reason I ask is that my current thinking on diagnosing my own hormone resistance vs bad pump site is that IF I level higher than I want (i.e. 220 or above is pretty telling), it is probably a hormone resistance issue for me assuming (a) I’m on a cycle day in which that would make sense and (b) if I am on Day 1 or 2 of my pod. I’ve been operating under the assumption that if my site is failing, my bg will probably continue to climb if no correction boluses are given. (Note that when I’m in a resistant state, I don’t continue to climb at my base basal rates. I just stay elevated but level.)

None of my statements above are perfectly accurate or fully tested; however, I’m trying very hard to come up with a good way to suss out when I’m seeing hormone resistance vs when I’m seeing a bad site.

For me, I end up doing quite a bit of fasting in these situations while I’m trying to eliminate variables and give correction boluses a chance. I assume you guys were in a similar position. I also try to keep all correction IOB within a recoverable range. If I get over 4 units IOB and it’s not doing what I want it to, I either need more basal or I need a new pod. But I’ve seen what a touch of extra basal can do when it is not required. It has all my respect in the world. Same goes for correction doses. Once they kick in for this type of scenario, it is a cliff. So I try to keep both in check and troubleshoot as best I can. The name of the game is Watchful Waiting for me…and little sleep…and lots of fingersticks…and lots of water. I dislike that game very much.

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Sorry that you guys spent so long (and a night up) battleing highs. That is never fun.

Sometimes this is really hard to distinguish from hormones. But my rule of thumb, generally, is to suspect the site before anything else. So I’ll generally change out a site before I’ll change a basal rate.

When I say two failed corrections, I don’t necessarily mean two corrections that don’t work at all in a row. It may be that the first correction brings me down a smidge and the second brings me down a smidge, but overall I’m still not within my target range. Or the first may not work at all and the second seems to bring me down, but then soon after I start rising again. Or, if I’m running a temporary basal rate, it may even be that that’s not bringing me down into range and then just one correction that doesn’t work (since the “temp basal” sort of counts as the other).

I also find testing for ketones to be a really useful tool in determining whether something is a site issue. For me, if I’m not fasting or eating low-carb or exercising intensely, a ketone level of 0.3 or 0.4 mmol/L, even though not technically high, raises my suspicion of the pump site. If I get a ketone level of 0.6 mmol/L or above and my BG is high, I change the site immediately and give an injection.

I don’t wear sites for more than 48 hours, and often wear a site only 12-24 hours (if it’s only 12 hours in, or even 24 hours in, I’ll move the needle to a new site but continue using the same infusion set).

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It was what we call a creeping high: starts slowly but does not yield to insulin. It took about 4 hours to get to 300 from 75. It did not stay there very long, and went down very fast: we had stacked a total of 14 units. The peak was out of range for about 6 hours.

I was interested in your statement about stabilizing high when you deal with hormones. This peak stopped at 300 because of the stacked insulin, not because it stops there naturally for us: when we get into hormone peaks, without very large amounts of insulin we keep climbing with no end in sight. In the past we have had to use 30U of insulin to deal with one of these highs.

Same here :slight_smile:

This is not something that we can often do in hormone peaks. They are very fast going. We normally see insulin activation in 45 minutes, but in these peaks it sometimes (rarely) takes longer, up to 1 hour 40. We typically give it about 1 hour before stacking, unless the climbing rate is low.

I am a bit envious here. We sometimes have to make corrections that are frightening in their volume when we get hit by a big peak. We do 10U corrections a couple of times a month, and we have had to do a 20U correction once. I get rather anxious when we reach this level of corrections.

How you get to a 20U correction: you already used a series of large corrections which did not visibly activate in the time you expected. You need to go down by 250 and you believe that your correction factor (CF) is worse than 1:15. We typically avoid injections of more than 5U, so this one would need 4 injections, for efficiency (and we always use a pen for large injections, btw).

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That is really interesting feeback for us. We typically did the opposite in the past. We’ll start putting more weight on likely site problems.

This happens to us a lot. But, in the past, I have put it down to a fast moving hormone peak. I might need to reexamine that with your eyes :slight_smile:

Very interesting too.

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Thank you for your thorough response, @Michel. I’m very curious and love to learn about what other diabetics experience…especially in the way of hormones and site failures. I want to emphasize that my questions are curiosity based and not judgment based. I don’t think you took offense to anything but re-reading what I wrote I just want to make sure.

Wow. I am feeling very grateful that to date I have not had to utilize that strong of correction dosing. I also find it very very interesting that your son’s hormone peaks are a steady climb with no end in sight. That is completely different than what I see with hormone induced insulin resistance of the female variety. It is good to discover these differences! It will surely inform my future conversations with people!

Interesting difference here, too. Mine are slow and sluggish.

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Totally not!!! Like you, I am extremely interested in how effects differ among all. I think this variety of symptoms also generates many different treatment options that are often revelating to others who experience different symptoms.

I have been reading with great interest the hormone threads of the women’s health section. In fact, it makes me realize I should also share sometime what kind of hormonal issues we see.

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Well, I don’t have terribly enlightening conclusions but I do have 24 hours of sludge to post about.

I started a new pod Wednesday night. It did fine overnight, although I know I rolled over it several times since I haven’t slept well this week and I was just starting my pods back on my right arm for October (I’ve gotten used to babying my left arm for last month’s pods on that side). Anyway, bg did fine Wednesday night and the first half of Thursday. But from Thursday after lunch through Friday morning, my numbers got stuck around 200. I kept pinging it with correction doses. I didn’t get any kind of blood sugar drop from my shower last night which was unusual. I was two days too soon to really suspect hormonal resistance but it’s always possible. I tried +5% basal through the evening and then +10% overnight. Correction doses overnight didn’t help.

I woke up this morning and was stuck at 240. So, thinking about site issue vs hormone issue, I decided to swap the pod early and see if that helped.

After trying several things after the pod change throughout the day (exercise, corrections, extra basal, water), it appears this IS a case of hormonal resistance. BUT, life doesn’t happen in a vacuum. I’ve slept terribly this week for variety of reasons and have a decent level of stress rocking and rolling right now. So that could cause the highs…but it really it looking like slightly early hormones which is not unheard of.

I’m glad I tried a new pod just to see how it panned out this time. Right now +10% basal is keeping me at 160 so I may need to kick that up to +15%.

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Nice detailed information here that I’ll need to reread to fully digest. Thank you all for posting!

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@T1Allison, did you by any chance come down with some cold it bout of sickness in the past 24 hours?

We often see this phenomenon with us: unexplained 20%+ incease I’m basal precedes sickness by 2-3 days.

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I was keeping an eye out for that, but 12 hours into the new pod I settled back down again to +0% basal.

Sometimes I wonder if once I get stuck in the stratosphere of bg if it takes my body a while to come back down (like 12-24 hours sometimes) even with all of the “right” changes.

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We wonder that too. Some of the highs are just so sticky.

I think that sleep disturbance is really a good thing that you put on. I definitely think that that can affect blood sugar so much! I hope that you’re getting more sleep soon! And that things settle down!

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