Troubleshooting Chronic Infusion Set/Site Issues

Resolving Chronic Issues From Continuous Subcutaneous Insulin Infusion

It is imperative that clinicians and people with diabetes develop effective problem-solving skills for detection, prevention and treatment of problems arising from continuous subcutaneous insulin infusion.

Follow this step-by-step troubleshooting process for chronic infusion set/site issues to prevent rapid deterioration of glucose management and avoid ineffective corrective steps.

Consideration: Chronic Recurrent infusion set/site issues require prompt attention and correction

Some, but not all, are preventable through proper training/education for the person with diabetes.

Possible Causes: Adhesion 

Preventative Action: When adhesion failures occur repeatedly, many individuals benefit from simply moving their infusion sets to a body part that moves/stretches/pulls/perspires less, such as the upper buttocks. 

Other strategies for improving adhesion:  

• Prior to insertion, make sure the skin is clean and dry, free of oils, lotions and perfumes.  
• Hairy sites should be shaved with (not against) the direction of hair growth the day prior to inserting the infusion set.  
• Adhesive agents may be applied to the skin prior to insertion.
• Over-bandages may be used to improve adhesion. With over-bandages, a hole may be cut in the center to allow access to the connect/disconnect mechanism.  
• To minimize the risk of accidental pull-outs due to snagged/pulled tubing, consider use of an infusion set that has a secondary disconnect site that adheres to skin. Otherwise, a “safety loop” can be made proximal to the disconnect mechanism. A small piece of adhesive tape placed over the loop can help to reduce risk of pulling directly on the infusion set. 

Possible Causes: Infection 

Corrective/Preventative Actions: Infections at infusion sites are relatively rare. However, all individuals should be careful not to allow the infusion set needle (or introducer needle) to touch anything prior to insertion, and to wear each infusion set for only two to three days. Users with a history of cellulitis, compromised immunity, staph or other skin infections are at an increased risk of site infections.  

A strong antiseptic should be applied to the skin prior to infusion set insertion. Individuals should be provided with signs/symptoms of site infections and instructed to seek medical attention at the first sign of erythema, edema, warmth, pus and blistering.

Possible Causes: Allergies  

Corrective/Preventative Actions: A variety of skin barriers can be used to minimize exposure to infusion set materials that may cause allergic reactions. In some instances, use of OTC antihistamine medications such as diphenhydramine can prevent symptoms and provide relief.  

For extreme/stubborn allergic reactions, individuals should be referred for dermatologic care.

Possible Causes: Lipoatrophy 

Corrective/Preventative Actions: Insulin absorption is impaired when infused into areas of skin that are affected by lipoatrophy or lipohypertrophy. 

Palpation of infusion sites at each office visit can aid in the detection of lipodystrophy. Feel for unusual indentations, inflammation, softness and hardness below the skin surface. Affected areas must be avoided to ensure proper and consistent insulin absorption.  

Note that temporary, minor inflammation is common at recently used infusion sites and may not indicate the presence of lipodystrophy. All insulin pump users should be instructed on proper infusion site rotation in order to prevent the development of lipodystrophies. This includes selection of appropriate body parts. 

ADDITIONAL RESOURCES

• Best Practices for Infusion Set Site Rotation
• Infusion Set Site Rotation Toolkit
• Infusion Set Teaching Checklist