Insulin Pump (CSII) Nursing Guide — GCC Clinical

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What is CSII? Continuous Subcutaneous Insulin Infusion (CSII) delivers rapid-acting insulin (NovoRapid/Humalog/Fiasp) via a programmable pump through a subcutaneous cannula. It replaces the need for multiple daily injections (MDI) and mimics the pancreatic insulin delivery pattern.

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How the Pump Works

Basal rate — continuous background insulin delivery (units/hour); multiple different rates programmable across 24 hours
Meal bolus — calculated from carbohydrate count × insulin:carbohydrate ratio (ICR)
Correction bolus — calculated from blood glucose deviation ÷ insulin sensitivity factor (ISF)
Insulin type: rapid-acting ONLY (NovoRapid, Humalog, Fiasp) — NO long-acting insulin
Reservoir: 300-400 units capacity; replaced every 2-3 days with cannula change

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Advantages of CSII over MDI

Tighter glycaemic control — lower HbA1c
Reduced hypoglycaemia (especially nocturnal)
Management of dawn phenomenon (programmable higher basal rate in early morning)
Flexible lifestyle — delayed meals, variable activity
Improved quality of life in patients with brittle T1DM
Useful in patients with recurrent hypoglycaemia unawareness
Can be combined with CGM for hybrid closed-loop systems

Closed-Loop (Artificial Pancreas) Systems

System	Type	CGM Used	Notes
MiniMed 780G (Medtronic)	Advanced hybrid closed-loop	Guardian 4	Auto-corrects basal and delivers micro-boluses; targets 100 mg/dL
Omnipod 5 (Insulet)	Hybrid closed-loop	Dexcom G6	Tubeless pod; smartphone control; increasingly available in GCC
Tandem Control-IQ	Hybrid closed-loop	Dexcom G6	Predictive low glucose suspend + auto-correction boluses
Manual pump + CGM	Sensor-augmented pump	Any CGM	Nurse/patient still calculates bolus manually

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Cannula Assessment

Change every 2-3 days — longer use increases infection and absorption failure risk
Site rotation essential — abdomen preferred (most consistent absorption)
Also: upper buttocks, outer thighs, upper arms
Inspect site at every change: redness, swelling, induration, leakage
Lipohypertrophy — fatty lumps from repeated same-site injection; impairs absorption
Signs of infusion failure: unexplained hyperglycaemia, ketonaemia

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Pump Alarms & Troubleshooting

No delivery/occlusion alarm — check for kinked cannula, air in tubing, blocked needle
Low reservoir — refill or change insulin cartridge
Low battery — replace battery (some pumps rechargeable)
Unexplained hyperglycaemia → assume infusion set failure until proven otherwise
Action: remove and replace infusion set at NEW site; administer correction dose by injection (not via pump until set confirmed working)

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Monitoring Parameters

Blood glucose (SMBG) or CGM readings
Time in Range (TIR) target: >70% between 3.9-10 mmol/L
HbA1c: aim <53 mmol/mol (7%) in most adults
Blood ketones if hyperglycaemia >14 mmol/L
Blood ketones >0.6 mmol/L = investigate infusion failure
Blood ketones >3 mmol/L = DKA — admit urgently

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Sick Day Rules — Critical: NEVER stop the basal rate during illness. Illness increases insulin requirements. Stopping basal insulin in a pump user leads to DKA within 4-8 hours (no long-acting insulin depot). Increase monitoring frequency to every 2-4 hours; check blood ketones; contact diabetes team early.

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Sick Day Rules (CSII)

NEVER stop the pump during illness
Check blood glucose every 2-4 hours
Check blood ketones if BG >14 mmol/L
If ketones >0.6: check infusion site, give correction by injection
If vomiting: contact diabetes team; may need IV insulin
Ensure adequate fluid intake
If ketones >3 mmol/L or vomiting/cannot drink: attend emergency department

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Surgery & MRI with Insulin Pump

Major surgery: remove pump; convert to variable rate IV insulin infusion (VRIII)
Minor surgery: may continue pump if patient able to self-manage; anaesthetist and diabetes team decision
MRI scan: must REMOVE pump before entering MRI suite (magnetic field will damage pump)
During MRI: give subcutaneous injections or temporary IV insulin
Document last bolus and basal rates before removal
Restart pump post-procedure when patient eating and drinking normally

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Patient Education — Essential Topics

Carbohydrate counting (mandatory for accurate meal bolusing)
Infusion set change technique (aseptic)
Site rotation and lipohypertrophy prevention
Troubleshooting hyperglycaemia and alarms
Sick day rules
Exercise adjustments (temp basal rate reduction for exercise)
Alcohol management
When to call for help
Pump suspension for swimming / sport

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Ramadan with Insulin Pump

Specialist nurse educator and endocrinologist review before Ramadan
Basal rates typically reduced by 20-30% during fasting hours
New basal rate profile programmed for Ramadan pattern (Suhoor/Iftar meal times)
Meal bolus timing adjusted to Iftar (break-fast) and Suhoor (pre-dawn)
Increased risk of hypoglycaemia during fasting hours — patient must be counselled on when to break fast (hypoglycaemia <4 mmol/L)
Blood glucose monitoring allowed during fasting (does not invalidate fast per most scholars)

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DKA Risk in Pump Users: DKA occurs FASTER in pump users than MDI users because there is NO long-acting insulin depot. If the infusion set fails (kinking, dislodgement, occlusion), insulin delivery stops completely. DKA can develop within 4-8 hours of unrecognised pump failure.

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Diabetic Ketoacidosis (DKA)

Most serious complication of CSII failure
Triggers: infusion set failure, illness, pump battery failure, empty reservoir
Signs: BG >11 mmol/L, ketones >3 mmol/L, pH <7.3, bicarbonate <15
NEVER manage DKA by increasing pump rate alone — switch to IV insulin protocol
Remove pump; start DKA protocol with IV insulin, IV fluids, potassium replacement

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Hypoglycaemia

BG <3.9 mmol/L = hypoglycaemia threshold
Causes: excessive bolus, missed meal after bolus, over-estimated carbohydrates, exercise
Suspend pump temporarily (most pumps allow 30-60 min temporary suspension)
Treat: 15-20g fast-acting glucose; recheck in 15 minutes
CGM with Low Glucose Suspend (LGS) can automatically suspend pump before hypoglycaemia

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Infusion Site Complications

Infection — cellulitis, abscess at cannula site; treat with antibiotics; change site
Lipohypertrophy — impairs insulin absorption; must rotate sites; avoid injecting into lumps
Bleeding/bruising — common; change site if persistent
Skin allergy — to cannula adhesive; use barrier wipes; change cannula type

🏥 CSII Availability in GCC ▼

DHA (Dubai): Insulin pump therapy available at Rashid Hospital and DHA specialty centres; reimbursement through DHA insurance schemes for T1DM patients meeting criteria
DOH (Abu Dhabi): SEHA hospitals offer CSII and closed-loop systems; DOH insurance mandates coverage for T1DM patients
MOH Saudi Arabia: CSII available at KAUH, KFSH&RC, and major tertiary centres; Vision 2030 healthcare expansion increasing access
Qatar (MOH/HMC): CSII available at HMC diabetes centres; increasing use of MiniMed 780G and Omnipod 5
Specialist diabetes nurse educators are essential — often the primary CSII educator and troubleshooter in GCC centres

🌙 Ramadan Fasting & Insulin Pump Management ▼

The GCC has the highest density of Muslim patients with T1DM attempting Ramadan fasting globally
Pump therapy offers significant advantages during Ramadan — programmable variable basal rates can be tailored to fasting/eating patterns
Typical Ramadan pump adjustments:
- Basal rates reduced 20-30% during fasting hours (dawn to sunset)
- Higher basal rate programmed for Iftar post-meal period
- Suhoor bolus: smaller dose (lighter pre-dawn meal)
- Iftar bolus: standard or slightly increased (larger meal)
Patients must be counselled to break fast if BG falls <4 mmol/L or rises >16 mmol/L
Pre-Ramadan assessment visit at least 4-8 weeks before Ramadan begins

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High-Yield Exam Points

CSII uses rapid-acting insulin ONLY (no long-acting)
NEVER stop basal rate during illness → DKA risk
DKA develops faster in pump users (no long-acting depot)
Cannula change every 2-3 days; rotate sites
Unexplained hyperglycaemia → suspect infusion set failure
Remove pump for MRI and major surgery
Ramadan: reduce basal by 20-30% during fasting
Closed-loop: MiniMed 780G and Omnipod 5

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Common Exam Traps

Never increase pump basal rate to treat established DKA — switch to IV insulin protocol
Lipohypertrophy = impaired (not increased) insulin absorption from that site
Blood glucose monitoring during Ramadan does NOT break the fast
Pump failure + illness = fastest route to DKA (double risk)
Correction bolus uses ISF (insulin sensitivity factor), NOT ICR (insulin:carbohydrate ratio)

Practice MCQs — Insulin Pump (CSII)

Q1. A T1DM patient on an insulin pump (CSII) develops gastroenteritis with vomiting. A junior nurse suggests stopping the pump to avoid hypoglycaemia. What is the CORRECT action?

A. Stop the pump as suggested — hypoglycaemia risk is too high when vomiting

B. Halve the basal rate until vomiting resolves

C. Continue the basal rate; check blood glucose and ketones every 2-4 hours; contact diabetes team urgently

D. Switch to subcutaneous long-acting insulin and stop the pump

Correct: C. The basal rate must NEVER be stopped during illness. CSII uses rapid-acting insulin only — there is no long-acting insulin depot. Stopping the pump will cause rapid ketone accumulation and DKA within 4-8 hours. Illness increases insulin requirements. Increase monitoring, check ketones, and contact the diabetes team.

Q2. A nurse is preparing an insulin pump patient for an MRI scan. What is the MOST important pre-procedure action?

A. Reduce the basal rate to minimum before entering the MRI suite

B. Remove the insulin pump completely before entering the MRI room; ensure alternative insulin coverage is in place

C. The pump can remain in place if the MRI field strength is <1.5 Tesla

D. Cover the pump with a lead shield to prevent MRI interference

Correct: B. Insulin pumps MUST be removed before entering the MRI room. The magnetic field will damage the pump motor, potentially causing over- or under-delivery of insulin. Ensure alternative insulin coverage (subcutaneous injections or IV infusion) is arranged for the duration, and restart the pump post-procedure when eating and drinking normally.

Q3. A patient on an insulin pump reports blood glucose of 18 mmol/L. The pump shows no alarms. What should the nurse check FIRST?

A. Administer an extra bolus via the pump immediately

B. Assume dietary non-compliance and document

C. Inspect the infusion site for kinking, dislodgement, or lipohypertrophy; check blood ketones

D. Increase the basal rate by 50% without further assessment

Correct: C. Unexplained hyperglycaemia in a pump user always requires inspection of the infusion site as the first action. Kinked cannulas, partial dislodgement, and lipohypertrophy are common causes of infusion failure. Blood ketones must be checked — rising ketones confirm insulin deficiency from pump failure. If infusion failure suspected, change the infusion set at a new site and give a correction dose by subcutaneous injection (not via the suspect set).

Q4. A Muslim T1DM patient on CSII is planning to fast during Ramadan. The diabetes nurse educator is adjusting the pump settings. What is the TYPICAL adjustment to basal insulin during fasting hours?

A. Increase basal rate by 20-30% to prevent Iftar-related hyperglycaemia

B. Stop the basal rate completely during daylight fasting hours

C. Keep basal rate unchanged and only adjust meal boluses

C. Reduce basal rate by 20-30% during fasting hours; programme higher rates for Iftar post-meal period

Correct: C (last option). During Ramadan fasting, basal insulin requirements decrease by approximately 20-30% during fasting hours (dawn to sunset) due to reduced caloric intake and lower glycaemic load. The pump's programmable basal rate profiles allow precise tailoring. Higher post-Iftar rates may be needed due to the typically larger evening meal. Pre-Ramadan review with specialist diabetes nurse educator is essential.