New T Slim pump user- Need advice

Type 1 and LADA
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Hi everyone!

I’m literally on Day 2 of using a Tandem x2 pump for the very first time, and feeling frustrated. I was a pen injection user for 27 years. Yesterday all went decently well and today it was as if my boluses didn’t exist. I checked and tubing etc seems to be in order. My sugar has been steadily climbing all day whenever I eat anything at all - I’m currently at 384 where I’ve been for 2 hours. It’s exceedingly frustrating. Does this mean my carbs and correction ratios are way off? I’m using Control IQ but it’s really uncomfortable to be this high for so many hours. Any advice? I’m trying not to go crazy but sheesh. I only ate 32 carbs for dinner.

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For me, if my carb counting is off or my ratios are off it does make me go high with spikes. I also notice if I don’t bolus early enough before I eat, I will spike too. What are you using to monitor your BG? Dexcom or libre or finger sticks? I find that a lot of CGMs are inaccurate the first day or two. Or there’s a leak in the actual infusion set piece. Like you can see insulin in the plastic area. Or I notice it’s leaking by touching the area and if it smells like insulin then it’s leaking. Tslim can’t pick up leaks,only occlusions. Hope this helps

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Thanks! I will check for leaks. I’m using Dexcom G6 and the pump is connected to my Dexcom for readings.

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Hi Sarah,

I’m sure you know this, but you’re high enough to check for ketones at 348 especially if it isn’t coming down. For piece of mind you might try giving yourself an appropriate correction with a pen. If that starts to bring you down, you might want to change your site and tubing.

Maurie

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I agree… you may have a bent or leaky cannula site, so insulin is not being absorbed.

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Thanks- I changed my tubing and it seemed to do the trick (wondering how the leakage started but nonetheless…) hoping for a better day today

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Are you using an Autosoft set? I’ve noticed training sucks on them. The details matter and it’s really easy to get bent cannulas (which block insulin flow) if you do it wrong.

You want to avoid pulling the infusion set up and off the introducer needle at all costs, which means absolutely no force in the direction the needle points, if that makes sense.

  1. Be sure to TWIST the blue needle cover until it spins freely before pulling it off. It really sticks to the cannula and just yanking it off carelessly will pull the set off with it. You can go ahead and push down on the paper spiral at this point just to make sure the set is fully seated.

  2. When unwinding the paper spiral adhesive backing, don’t pull it straight up. Instead pull it off to the side. Your fingers should circle all around the UFO-shaped inserter.

  3. Don’t tuck the tubing into the half-circle cutout until AFTER the mechanism is cocked for insertion to avoid unnecessary tugging.

  4. Keep your fingers clear of the moving parts so you don’t stop the insertion needle prematurely.

This all just takes a moment of extra awareness, but resolves a TON of set frustration.

Also, some people have trouble with air bubbles on the third day, if you didn’t get all the air out if the cartridge. Check the tubing to be sure you’re not just pumping air!

It’s also entirely possible that infusion sets don’t last you a full three days. If you’re immune system is in overdrive or you have inflammation issues, you may stop absorbing insulin there before the three days is up. You definitely want to be in the habit of changing your sets BEFORE your BG starts spiking, to avoid accumulating scar tissue. Your doctor can change your prescription to change sites every 2 days instead of three, if need be. You can change the infusion set independently of the cartridge, so it’s real quick to just insert the new set, plug in the old existing tubing, fill the cannula and go.

One last tip. I learned exactly one useful thing at my pump training: that a new site needs to be flooded with insulin before it really starts absorbing the insulin. Even though my set only requires 0.3 units to fill the cannula, my trainer suggested I use the 0.7 option to prime my flesh, so to speak. I’ve since learned that I require much more than that to avoid spiking after a new set. I have to exit the load screen and come back to fill the cannula a second time to get all the priming I need. It’s made a massive difference in the "third day blues"for me!

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Welcome back to TuD, @Sarah32! You’ve received some great suggestions to think about your insulin mis-delivery issue. Using your nose to detect an external insulin leak is a good one.

Good luck with your new pump. It’s always exciting to get some new diabetes tech but then missing the comfort of “tried and true” routines can be stressful. I’m sure you will figure out the X2 and benefit from the automated insulin dosing.

Do you have any blood ketone strips on hand? You might look into that as it’s an important (although infrequently needed) safety system.

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You can test it by overriding the delivery.
If I know it should be 6 units and my pump says something different I will just enter the insulin I want to take and over rode it. You can figure what’s wrong w settings later.

You need to have your weight accurately set
You need your sensitivity needs to be set
Then your carb ratio

It took me a few months to get it smooth, but in the meantime you can bolus more when you need to

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@Sarah32 , I am a 20+ year pump & Dexcom (various models) user. I have been on CIQ for 19 months.

In regard to your 384, I would share, pen down. Leave CIQ on, check your site.
I worry about your training because you are asking us for help.

CIQ is so different than anything else in the D world because of the integration of the CGM reporting to pump software and the pump software ‘autopiloting’ your pump.

The first lesson you need to keep in your head is PATIENCE. You shared you have been doing MDI for 27 years. This is great. You know how fast the insulin from your pen works in your body. Humorously, we know insulin, regardless of injection method, works “INSTANTLY” - - - NOT!

The same speed of action is true with a pump. So, lesson one is pumped insulin is no faster that penned insulin. Next, Tandem pumps can only use Novolog or Humalog. I hope you used one of these in your pen journey.

The next lesson is TRUST. If the system looks good trust it. If the system looks wonky, check out problem areas.

Here is my collection of thoughts:

Welcome to CIQ Airways. LOL+GRIN

Learn as much as you can about CIQ & CGM so you can use the tool to the maximum

Using CIQ will be like a well programmed (once your numbers are fine-tuned) autopilot. You will learn the key is in the line with the blue boxes. It is those blue boxes in a line telling you what CIQ is doing for you.

CIQ will kick in on reports from CGM and throttle insulin accordingly. CIQ connects the dots and looks 20-30 minutes in the future to make decisions.

When you have your training session there are many things you will need to master. It is helpful for you to request several things in writing you may take with you when you leave.

Here is a suggested list of written documents:
[1] written site change instructions specific to your site set.
[2] written sensor change instructions from Tandem.
[3] written transmitter change instructions from Tandem.
NOTE: Learn where to start changes - start with the pump in both cases. Your phone will catch up on sensors. Do both the pump and phone with transmitters. Much will be said about this.
[4] written guides about avoiding calibration rabbit holes.
[5] written guidelines about when to call for technical support.
[6] your own questions – written and taken to training.

From your endo, you should have these documents:
[1] Site failure protocol/procedure.
[2] Pump failure protocol.
[3] Recommendation for Pump Emergency Kit contents.
[4] How to share pump and CGM data with endo’s office & team.

When you complete your training:
[1] you should have all the above questions answered, in writing.
[2] a copy of the signed Tandem Insulin Pump Training Checklist.

To help, create an Emergency Action Plan (EAP).

Pick three descending CGM numbers like 85, 75, 65 or whatever works well for you, your endo, & pump training team. Set your alarms to sound at these numbers. Apps like t:Connect, G6, & SugarMate work well for many.

At 85 and going down - start being aware a fall is in the future.
At 75 and going down - investigate the reason the fall is occurring and what t:Connect is displaying.
Ask yourself,
what is tC doing?
Is insulin already off?
Consider stopping activity you associate with LOWS.

At 65 and going down - consider a SMALL carb snack and closely observe what the CGM is reporting and the way CIQ is controlling the pump.

CAUTION: At 65 and level or with slight elevation, consider your hold on activity and observe the way CIQ is responding to CGM reports. One of the observations some share is if CIQ has held insulin for more than 30 minutes, the resulting climb out of the low will be a little higher than desired. Fret not, CIQ will see this and if you are continuing to observe tC, CIQ will respond by elevating the insulin basal rate above the basic basal dose for that time period. WATCH, CIQ will perform slow magic.

Hope this helps.

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@Sarah 32, here is the training outline from Tandem you should have received a copy of when you had CIQ training. Check it out.
a_qsf-0002814_j-insulin-pump-training-checklist-(covid).pdf (259.0 KB)

Check your training against this document.

The next is the Tandem CIQ big USER GUIDE

Here is the link to a PDF version I would suggest you load on tablet or computer for easy searching and answer location.

CIQ User Guide (350+ pages and is best put on a tablet or computer for easier searching)

https://www.tandemdiabetes.com/docs/default-source/product-documents/t-slim-x2-insulin-pump/käyttöopas-(t-slim-x2--pumppu-control-iq-teknologialla)cf14759775426a79a519ff1100a9fd393f6fb39775426a79a519ff1200a9fd39.pdf?sfvrsn=18a507d7_66

The final piece is about calibration in general and how it relates to CIQ

CGM Calibration Facts & Rationale to Avoid Pitfalls

CGM Calibration Facts & rationale to avoid pitfalls & rabbit holes
NOTE: The term “rabbit hole” comes from the 1865 piece “Alice’s Adventures in Wonderland” by Lewis Carrol 1865 and has come to mean a bizarre, confusing, or nonsensical situation or environment, from which it is difficult to extricate oneself.

Test by finger stick (FS) anytime CGM doesn’t seem to match the way you feel.

Learn & verify acceptable deviation according to FDA approvals, ±20% above 100mg/dL and ±20mg/dL below 100. Examples, CGM =200, then FS can be between 160 & 240 and still be fine, or CGM = 70, then FS should be between 50 & 90 with level CGM.

Wait 60 minutes between tests if testing for CGM for validation.

Remember, CGM measurements are interstitial fluid and finger sticks are whole blood and glucose doesn’t move instantly.

Whole blood & interstitial fluid are physiologically different & 15-20 minutes apart in the movement of glucose.

Call tech support if 2 tests are >20% off, 1 hour apart. You may need a new sensor or have other technical issues.

Only enter calibration with great consideration. This reduces the number of times you will get into the calibrate, calibrate, calibrate, rabbit hole. There are many who have avoided or not needed calibration for months after understanding the CGM actions.

If you are calling tech support for a goofy sensor, request replacement, regardless.

Follow tech support about changing a sensor.

Avoid the calibration rabbit hole of the system requesting multiple calibrations for hours and sometimes days.

Not everyone (some doctors) who prescribed insulin fully understands CIQ & how it uses CGM. See Section 3:CGM Features to learn more.

Why FSs & CGMs don’t play nice together.

First, FS & CGM are only expected to be within 20% of each other according to published standards accepted in the USA by the FDA. If your CGM says 200 then ±20% is ±40 mg/dL meaning a finger stick is fine if it is between 160 & 240. At the same time if CGM says 100 the ±20% would be 80 to 120. BELOW 80 it is ±20 points (mg/dL) without the percentage according to US FDA standards.

NOTE: Some individuals expect much narrower values between FS & CGM, even to the point of expecting them to match spot on, every time, all the time. This is unrealistic.

Second, as food is eaten, the food enters the blood stream in various places along the digestive tract. Some enters quickly from the mouth, like granular sugar placed under the tongue. Other foods swallowed quickly may not enter the blood stream until arriving in the stomach. The final absorption occurs in the small intestine.

After food is absorbed into the blood stream, it is ‘checked’ by the liver and then dispatched thru the body in the blood stream.

After glucose is in the blood stream, the glucose moves in the liquid part of the blood (sometimes referred to correctly as plasma or serum - like serum or plasma glucose for the doc’s office or hospital blood test) into the interstitial fluid that moves around all body cells outside the blood vessels. It is this interstitial fluid that CGM sensor wires are in to read the glucose and report it to our measuring devices.

The time for all of the glucose movement to take place is usually 15-30 minutes or more, depending on multiple variables including the amount of carbohydrates, proteins, & fats in the consumed food which changes the way the food is processed in the body.

It is this 15–30-minute interval and body fluid differences that give significant part to the variation in CGM and FS readings. This is also the reason most comparisons are done when glucose values are demonstrated level by the CGM before doing comparison finger sticks.

Here are two pages from the Dexcom website (USA) that will explain the difference. Others have given varying information. Here is the info straight from Dexcom.

If you are not in the USA, you can change the country in the upper right corner of each web page. For example, some countries use mmol/L instead of mg/dL.

Several members of this group & similar groups believe answers should include references.

Wish they would play nice together……