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October 16, 2007

Hyperglycemia and DKA, Insulin Pumps

Question from Neptune, New Jersey, USA:

What can you tell about the Cumberland Hospital for Children and Adolescents? My daughter's endocrinologist says that unless she goes there for treatment, he will stop seeing her. She has been in DKA twice in the past year. Also, have you heard of anyone having trouble with the MiniMed 715 not recording all of the boluses and fingersticks? Her endocrinologist says that it impossible and that she just is not doing it. We have watched her. MiniMed did replace the pump and she seems to be doing better.


Yes, I have had problems with various pumps not recording accurately all the boluses. I’ve checked the memories myself and have found, at times, that the totals in the memory do not equal the sum of the individual doses. I do not remember specifically which pumps had problems, but there was at least one MiniMed pump. Make sure the company gives you a new pump, not a refurbished pump. I have written previously about my experience with Cumberland. I think you would do better with a local team. Although Cumberland does well with the teens when they are there, they don’t work with the local team for follow-up and I find the kids usually have the same problems when they return.

If you think you are having pump problems, you may want to switch to injections for a while to establish whether this is a psychological problem or a mechanical problem or both. I find that often teens who previously liked the pump get tired of it, are afraid to tell their parents or doctors that they want to come off the pump and instead do not bolus. (this is MUCH more common than pump memory problems which are EXTREMELY rare – you can only document the pump problems by finding a discrepancy between the totals and the individual doses or if a parent of physician personally delivers a bolus and documents that it is not recorded in the memory).

Additional comments from Dr. Stuart Brink:

Recurrent DKA is a psychosocial problem about 99% of the time and involves omitted insulin almost always. One can have extremely high blood sugar readings if overeating, but it requires severe insulin deficiency or something that blocks insulin action to have ketoacidosis, especially more than once without another explanation (surgery, illness, steroid medications, etc). I have never heard of the pump failing to record insulin boluses and the best way to ensure that this is so with your child is for you or any other responsible adult to always be present and always watch directly that the bolus is given and delivered. All episodes of recurrent DKA stop when an adult takes charge of the insulin delivery – whether by syringe or pen or pump. This is what would happen at a hospital such as Cumberland or at any other hospital for recurrent DKA. I would suggest going back to have a consultation visit with your diabetes team sort out what options you have to consider.

Additional comments from Dr. Linda DiMeglio:

In my clinical experience, there have been many, many missed boluses at mealtimes in my patients with diabetes. None have ever been attributable to the pump “not recording” boluses. It is possible to download the pump and look at all the settings, setting changes, and bolus history (as well as manually scrolling through the pump). If the pump self-test shows that it’s working right and nothing else is amiss in the download, I would conclude that the missing information is not there because it was not done and not because the pump memory “lost it.”

If your daughter is using the BD meter and expecting the meter to transmit the blood glucoses to the pump, that transmission may not always be working properly. A check of the meter, though, should show whether or not the glucose testing was actually done.


[Editor’s comment: Three other Diabetes Team endocrinologists also indicated they have not seen pumps “missing boluses.”