Continuous Glucose Monitoring CGM
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Real-Time Revel System, Guardian Real-Time and the Navigator have these
21
Barbara Davis Center for Childhood Diabetes April 2010
Real Time data
TREND ARROWS
Understanding Pumps and CGMs, p.100
Barbara Davis Center for Childhood Diabetes April 2010
4
WHY Use CGM?
A. Prevention of low blood sugars (alarms) B. Prevention of high blood sugars (ketones) C. Minimize wide glucose fluctuations D. Behavior Modification E. Prevention of Complications (?)
Arrows that indicate the rate and direction of change
Barbara Davis Center for Childhood Diabetes April 2010
Glucose rising quickly >2 (mg/dL)/min
Glucose going up 1 to 2 (mg/dL)/min
Fairly stable glucose -1 to 1 (mg/dL)/min
Glucose going down -1 to -2 (mg/dL)/min
Barbara Davis Center for Childhood Diabetes April 2010
11
Three Parts to CGMs:
A. Sensor
B. Transmitter
C. Receiver/Monitor
Understanding Pumps and CGMs, p.103
INTRODUCTION TO CONTINUOUS GLUCOSE MONITORS
H. Peter Chase, MD
Vicky Gage, RN, CDE Laurel Messer, RN, CDE Susie Owen, RN, CDE Sally Sullivan, RN, CDE
Barbara Davis Center for Childhood Diabetes April 2010
1
Agenda
• Dr. Chase will present a general CGM overview
• Nurses will explain device features and comparisons between sensors
• You will have an opportunity to handle each device and ask questions
are stable: before meals and before bed • Do not calibrate when arrows are present
Barbara Davis Center for Childhood Diabetes April 2010
16
What type of data will we get?
Real Time data
Alarms continued
Threshold alarm:
Warning when glucose is above or below a set value
--all devices have this
Projected Alarms:
10,20 or 30 minute warning of Impending hypo- or hyperglycemia
• Calibration is a process that gives a fingerstick BG value to the CGM system so the values will align with each other
• Number of Calibrations vary by device • Best times to calibrate are when the BG values
17
Real Time Data
Three types of Real Time Data: A) Trend graphs B) Alarms C) Trend Arrows
Understanding Pumps and CGM: pages 109-113
Barbara Davis Center for Childhood Diabetes April 2010
18
Real Time data
TREND GRAPHS
Trend graphs – Knowing a glucose level is 240 mg/dl may not be as important as knowing the “trend.”
Understanding Pumps and CGM: p.103
Two types of CGM data: • Real Time data: seen on CGM • Retrospective data: download
to a computer
Barbara Davis Center for Childhood Diabetes April 2010
Barbara Davis Center for Childhood Diabetes April 2010
2
What is a CGM? (Continuous Glucose Monitor)
• A device that provides “real-time” glucose readings and data about trends in glucose levels
B) 2004: 14 of 50 (28%) with low BG
(all on insulin pumps or Lantus)
(i) Beregszaszi M, et al. J Pediatr. 131, 27, 1997 Barbara Davis Center for Childhood Diabetes April 2010 (ii) Porter PA, et al. J. Pediatr. 13, 366, 19967
• The 3rd era in diabetes management
Barbara Davis Center for Childhood Diabetes April 2010
3
Who Should Use a CGM?
1) The person and the family must both want a CGM
Barbara Davis Center for Childhood Diabetes April 2010
5
How common are glucose levels <60mg/dl during the night in children with T1D?
– French (i) and Australian (ii) data showed approximately 50% of children with low BG (<60mg/dl) during the night (on NPH bid)
Barbara Davis Center for Childhood Diabetes April 2010
14
C) Receiver or Monitor
(p.103)
Barbara Davis Center for Childhood Diabetes April 2010
15
What does “Calibration” mean and why do I need to do it?
Barbara Davis Center for Childhood Diabetes April 2010
7
“Snapshot of BG levels”
Barbara Davis Center for Childhood Diabetes April 2010
8
Continuous Glucose Monitoring
– DirecNet data (one night in hospital with blood sugars every 30 min.)
A) 2001-2002: 39 of 91 (43%) low BG
(44% of children on insulin pumps/56% on NPH)
Barbara Davis Center for Childhood Diabetes April 2010 Boland et al, Diabetes Care 24:1858,120001
WHY Use CGM?
A. Prevention of low blood sugars (alarms) B. Prevention of high blood sugars (ketones) C. Minimize wide glucose fluctuations D. Behavior Modification E. Prevention of Complications?
Barbara Davis Center for Childhood Diabetes April 2010
12
A) Sensor
(p.103)
Barbara Davis Center for Childhood Diabetes April 2010
13
B) Transmitter
(p.103)
2) A youth must be williny the receiver)
3) Using good diabetes care (4 BGs/day) 4) Good support system 5) Adequate body “real estate” 6) Cost of CGM (RNs to elaborate)
Barbara Davis Center for Childhood Diabetes April 2010
Real Time data
ALARMS
Warn patients of current or
projected high and low blood
sugar
Barbara Davis Center for Childhood Diabetes April 2010
• Reads the glucose levels under the skin every 15 minutes (10-15 minute delay)
• Provides alarms for high and low glucose levels and trend information
WHY Use CGM?
A. Prevention of low blood sugars (alarms) B. Prevention of high blood sugars (ketones) C. Minimize wide glucose fluctuations D. Behavior Modification E. Prevention of Complications (?)
Barbara Davis Center for Childhood Diabetes April 2010
9
Hyperglycemia is common, especially after meals
50%
40%
30% 20% 10%
Breakfast Lunch Dinner
0% < 180 181 - 240 241 - 300 > 300
21
Barbara Davis Center for Childhood Diabetes April 2010
Real Time data
TREND ARROWS
Understanding Pumps and CGMs, p.100
Barbara Davis Center for Childhood Diabetes April 2010
4
WHY Use CGM?
A. Prevention of low blood sugars (alarms) B. Prevention of high blood sugars (ketones) C. Minimize wide glucose fluctuations D. Behavior Modification E. Prevention of Complications (?)
Arrows that indicate the rate and direction of change
Barbara Davis Center for Childhood Diabetes April 2010
Glucose rising quickly >2 (mg/dL)/min
Glucose going up 1 to 2 (mg/dL)/min
Fairly stable glucose -1 to 1 (mg/dL)/min
Glucose going down -1 to -2 (mg/dL)/min
Barbara Davis Center for Childhood Diabetes April 2010
11
Three Parts to CGMs:
A. Sensor
B. Transmitter
C. Receiver/Monitor
Understanding Pumps and CGMs, p.103
INTRODUCTION TO CONTINUOUS GLUCOSE MONITORS
H. Peter Chase, MD
Vicky Gage, RN, CDE Laurel Messer, RN, CDE Susie Owen, RN, CDE Sally Sullivan, RN, CDE
Barbara Davis Center for Childhood Diabetes April 2010
1
Agenda
• Dr. Chase will present a general CGM overview
• Nurses will explain device features and comparisons between sensors
• You will have an opportunity to handle each device and ask questions
are stable: before meals and before bed • Do not calibrate when arrows are present
Barbara Davis Center for Childhood Diabetes April 2010
16
What type of data will we get?
Real Time data
Alarms continued
Threshold alarm:
Warning when glucose is above or below a set value
--all devices have this
Projected Alarms:
10,20 or 30 minute warning of Impending hypo- or hyperglycemia
• Calibration is a process that gives a fingerstick BG value to the CGM system so the values will align with each other
• Number of Calibrations vary by device • Best times to calibrate are when the BG values
17
Real Time Data
Three types of Real Time Data: A) Trend graphs B) Alarms C) Trend Arrows
Understanding Pumps and CGM: pages 109-113
Barbara Davis Center for Childhood Diabetes April 2010
18
Real Time data
TREND GRAPHS
Trend graphs – Knowing a glucose level is 240 mg/dl may not be as important as knowing the “trend.”
Understanding Pumps and CGM: p.103
Two types of CGM data: • Real Time data: seen on CGM • Retrospective data: download
to a computer
Barbara Davis Center for Childhood Diabetes April 2010
Barbara Davis Center for Childhood Diabetes April 2010
2
What is a CGM? (Continuous Glucose Monitor)
• A device that provides “real-time” glucose readings and data about trends in glucose levels
B) 2004: 14 of 50 (28%) with low BG
(all on insulin pumps or Lantus)
(i) Beregszaszi M, et al. J Pediatr. 131, 27, 1997 Barbara Davis Center for Childhood Diabetes April 2010 (ii) Porter PA, et al. J. Pediatr. 13, 366, 19967
• The 3rd era in diabetes management
Barbara Davis Center for Childhood Diabetes April 2010
3
Who Should Use a CGM?
1) The person and the family must both want a CGM
Barbara Davis Center for Childhood Diabetes April 2010
5
How common are glucose levels <60mg/dl during the night in children with T1D?
– French (i) and Australian (ii) data showed approximately 50% of children with low BG (<60mg/dl) during the night (on NPH bid)
Barbara Davis Center for Childhood Diabetes April 2010
14
C) Receiver or Monitor
(p.103)
Barbara Davis Center for Childhood Diabetes April 2010
15
What does “Calibration” mean and why do I need to do it?
Barbara Davis Center for Childhood Diabetes April 2010
7
“Snapshot of BG levels”
Barbara Davis Center for Childhood Diabetes April 2010
8
Continuous Glucose Monitoring
– DirecNet data (one night in hospital with blood sugars every 30 min.)
A) 2001-2002: 39 of 91 (43%) low BG
(44% of children on insulin pumps/56% on NPH)
Barbara Davis Center for Childhood Diabetes April 2010 Boland et al, Diabetes Care 24:1858,120001
WHY Use CGM?
A. Prevention of low blood sugars (alarms) B. Prevention of high blood sugars (ketones) C. Minimize wide glucose fluctuations D. Behavior Modification E. Prevention of Complications?
Barbara Davis Center for Childhood Diabetes April 2010
12
A) Sensor
(p.103)
Barbara Davis Center for Childhood Diabetes April 2010
13
B) Transmitter
(p.103)
2) A youth must be williny the receiver)
3) Using good diabetes care (4 BGs/day) 4) Good support system 5) Adequate body “real estate” 6) Cost of CGM (RNs to elaborate)
Barbara Davis Center for Childhood Diabetes April 2010
Real Time data
ALARMS
Warn patients of current or
projected high and low blood
sugar
Barbara Davis Center for Childhood Diabetes April 2010
• Reads the glucose levels under the skin every 15 minutes (10-15 minute delay)
• Provides alarms for high and low glucose levels and trend information
WHY Use CGM?
A. Prevention of low blood sugars (alarms) B. Prevention of high blood sugars (ketones) C. Minimize wide glucose fluctuations D. Behavior Modification E. Prevention of Complications (?)
Barbara Davis Center for Childhood Diabetes April 2010
9
Hyperglycemia is common, especially after meals
50%
40%
30% 20% 10%
Breakfast Lunch Dinner
0% < 180 181 - 240 241 - 300 > 300