TSlim X2 and High BG Questions

My 13 year old year old was diagnosed in April and we were so excited when we were approved for the TSlim X2 so we would have less needle sticks and be in range more often. However we are seeing a lot of high BGs and are having second thoughts. This is the first pump we’ve used. We are using the Autosoft 90 infusion set and from what I’ve read the 90 has frequent issues with bent cannulas. We’ve seen this to be true because when we’ve removed the insfusion set the cannula is bent. So I was wondering if anyone had any advice. We’ve talked to tandem support and they are sending us the Autosoft 30, Trusteel, and whatever the other set is called to try but my question is does the TSlim always alarm if the cannula or tubing is bent or kinked, or leaking? Is it possible the insulin is not being delivered but we receive no occlusion alarm? At this point we are confused as to if it’s an infusion set issue, miscalculated carbs, or just typical middle school aged hormones. At least with the pens we knew the insulin was going in!
Also does anyone frequently change the carb ratio? For example if bg is high before eating a meal, do you use do a 1:10 ratio instead of 1:12? I ask this because the first 24 hours we were seeing BGs between 250 and 300 so I called our dietician/pump trainer and was told not to make any changes and that higher numbers were to be expected during the first 24 hours. We also saw trace to small keytones and the dietitian said she was not concerned. She said they were more concerned with lows than highs, which I found concerning because I feel our doctors should be equally concerned with both.

Hi @WarriorMom13 I think the most important thing is to have observations and to discuss them with his doctor.

A few things come to mind. When I have a partially occluded site I see high blood sugars but don’t get an occlusion alarm. This has happened many times in the last 17 years. For some people, 90 degree sets can be problematic. For others the 30 degree sets can be problematic. :slight_smile: It is very helpful to note that if the blood sugar comes right down with a shot, that’s it is likely the set.

No pump has the ability to alarm consistently or absolutely for a partially blocked or leaking set.

Another thing is that during the first year, your sons need for insulin could increase dramatically. Diabetes isn’t something that you get your settings and basal and that’s it, after 40+ years I still need to adjust, even if it is just a little bit. For a newly diagnosed teenager, it wouldn’t shock me if his insulin needs change by a large percentage.

Occasional basal, carb ratio, and sensitivity testing and adjustment may be needed.

I hope you can take your notes to his doctor and I hope that things return to a more “regular crazy” (I only say that because it’s the way diabetes is). :four_leaf_clover:

I’m so sorry you’re dealing with this! Sadly, we had exactly the same experience. We tried every infusion set they make, and we worked diligently with a LOT of different people (multiple endos, CDEs, Tandem reps, you name it), but we never did find a Tandem-brand solution for my daughter (who is also 13 now; diagnosed at 6). So we went back to Omnipod, which works well for us. Best I can figure is it had something to do with the tubing for us, since that’s the only constant. I do think we’re the exception — lots of people love their Tandems, and any difficulties they have can be remedied with a different infusion set. So hopefully that’s you, too. :crossed_fingers:

Thank you Susan. I sure hope we can find a solution using the x2! We’ve been told we are stuck with it for 4 years…I guess because of insurance. So far today we are seeing much better numbers. We changed the site to his leg instead of the abdomen this time and made a “safety loop” with the tubing like the tandem support recommended. We didn’t go with Omni because we wanted the control IQ that works with the Dexcom G6. Plus the X3 seemed easier to conceal than the Omni. My son hasn’t told hardly anyone at school, just a couple of closest friends…so he tries to hide the pump. I worry about this, and have tried to encourage him to try to use it as a way to teach others about T1D but he’s afraid people will think he’s weird (his words) or treat him differently.

Hi @WarriorMom13 . Kids can be self conscious but as time goes on he might be more comfortable opening up. That said, it’s not necessary to tell everyone. There are people I worked side by side with for years who didn’t know, and people I shared with early on.
You might check with the school nurse to see if there are any other kids with Type1 who would like to connect with him - there may be a few “secret diabetics” he could meet. Also check your local JDRF chapter - there may be activities in your area that would interest him. It’s under the Resources tab.
Also sorry to hear about your infusion set struggles. People may find certain ones easier to work with so by all means try the options. You might sit down with your trainer or nurse educator again for a refresher - they could check your technique. FWIW, I’ve been pumping for about 30 years and use Autosoft 30 and (occasionally) the 90 degree XC. A few months back I stayed having trouble with the 30s - I kept going high for no logical reason. It turned out my cannula was bent but I couldn’t understand what I was doing wrong. I took a slow, careful look as I was inserting one day and discovered I was tilting the applicator when I should not have. Don’t know why I did it but it was causing the cannula to bend. Once I laid out flat, no more problems. So check your technique for your 30s and for the new ones you try. Hopefully you’ll find the right one.

Yes I told him it was his choice as far as who he told and when. I’ve also shown him this forum and JDRF. I guess I worry because trying to hide the pump seems to cause more stress than just clipping it to his waistband. I don’t know I think sometimes I just over worry about everything. I have the utmost respect and empathy for all of us dealing with T1D because it is tough! Some days I do well but others not. For us the issue is mostly too high BGs but I keep reading where a lot of people experience middle of the night lows. Unfortunately I tend to be somewhat of a perfectionist and with this I suppose I need to learn there is no perfection, and to take each day… each meal as it comes.
Thank you for the responses!

Also does anyone frequently change the carb ratio? For example if bg is high before eating a meal, do you use do a 1:10 ratio instead of 1:12? I ask this because the first 24 hours we were seeing BGs between 250 and 300 so I called our dietician/pump trainer and was told not to make any changes and that higher numbers were to be expected during the first 24 hours. We also saw trace to small keytones and the dietitian said she was not concerned. She said they were more concerned with lows than highs, which I found concerning because I feel our doctors should be equally concerned with both.

Hi again. I’m responding to your post in bits and pieces - sorry.
Regarding carb ratios, you may need different ones for different times of day (I’m 1:8 at breakfast and 1:10 the rest of the day), but you should go with what is in place unless instructed otherwise by your doctor. Keep in mind, I’d you were to change the ratio for one meal and forget to set it back you would probably be looking at problems later on.
Lows can cause a more urgent situation in the short run. No one wants highs either, especially if they are frequent and last for long. But widget during the honeymoon stage, when the body might add in songs insulin of its own, it may be safer to allow for some higher numbers. Even after the honeymoon a teen’s body is going to be susceptible to the effect of hormones on his body, but eventually things will become a little more stable and predictable.
BTW, if you don’t have one look into getting a good tracker. There are diabetes apps you can download (SugarMate and MySugr are popular and I believe free), or you can use pencil & paper or get one from your local bookstore. The more vigilant I am about recordings my food, doses, exercise, etc. the better able I am (and maybe my doctor/nutritionist/DNE) to find patterns.
Try to set aside your expectation of perfection. There are a lot of variables some of which we can’t control, so work on doing the best you can and learning to correct. When it comes to my CGM numbers I like to think of them as a bike ride: on the one hand, your have the mountain portion of the Tour de France, with jagged peaks and drops. I’ve had some recent days where my graph looked like that. Then there’s a ride through a park - relatively flat with some small hills and dips, but few if any extremes either way. That’s my dream graph. Sometimes I get it, but sometimes I hit one of those peaks or dips and have to fix it and continue “the ride.”

Joanna @WarriorMom13 , most of what I might have written has already been said, so I will be very brief.

If you are using the t-Slim dose calculator, do NOT adjust the I:C ratio just because BG happens to be higher than wanted at meal-time. The recommended dose has been adjusted, based on the ISF [correction factor] programmed in the Profile. The ISF may need adjustment if the dose calculated indicated a pattern of not making proper adjustments of the dose. Additionally, I:C ratios needed are not the same 24 hours a day.

A pump will not necessarily improve TIR [time in range] just because one is using one - lots of other factors are still in play, and hormones play a huge part. I did begin with a pump after 47 years of injections primarily to eliminate thousands of needle-sticks. With my t-Slim, I have primarily used the AutoSoft 30, 13 mm which has been extremely effective on my abdomen; on arms I’ve used the 90 degree 6 mm and 9 mm.

If some, or all, insulin is leaking out at infusion site orr from loose connections in tubing, I do not believe the t-Slim could detect and send an Alert; I think he might need to be aware of a “wet feeling” on skin or clothing.

hope that you soon find the right infusion set, for in the long run a pump will make diabetes management much more convenient for him - with a small sacrifice of “optimal management”; I’m now using my 4th pump.

My insulin sensitivity varies throughout the day. I use a 1:7 ratio for breakfast, a 1:10 ratio for the afternoon and a 1:15 ratio for the evening and night. Ratio changes are necessary for me.

We had a similar experience with the autosoft 90. There’s someone who posted a really good video on YouTube regarding how to prevent the bent cannula problem with them. One thing I realized I was doing wrong was this: after insertion, I was lifting up on the injector and having trouble getting it to release. So I would push up and down on it to both “help the adhesive stick” and to be able to release the round thing. Evidently doing that can bend the cannula. The man In the YouTube video demonstrated how to use a credit card or thin piece of cardboard to hold the adhesive down while pulling up on the round thing. The up and down motion was a bad idea.
We then used the TruSteel for quite a while. Those worked great for a long time but then, for some reason we began to have problems about every 5th infusion set change. I have no idea why this was happening!
About 2 months ago we switched to the Autosoft 30 and HURRAY! So far so good! Our daughter is slim and our local Tandem rep said those infusion sets work really well for slim people.
We don’t fool with I:C or ISF without advice from our endo or CDE.
Control IQ is fantastic. A game changer for us.

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As always, there is a lot of great advice already given. I wanted to add my thoughts. When you mentioned about using a different carb ratio, depending on pre meal sugars, I wanted to make sure you look at correction factors as well. There should be settings in place that give extra insulin for those higher pre meal BGs.
I can also add that it can be hard to judge whether it’s the site, hormones, food, exercise or lack there of…etc. There are many variables, esp during puberty. My 11 yo son will eat the exact same breakfast, dose the exact same amt, and some days be great and others will shoot up to 300. I try not to overthink anything that isnt a trend. If it’s a day of high numbers, that aren’t responding, then my 1st thought is site. If they spike, but respond, then I think…hormones? Stress? When was his last activity?

I have had t1d for 35 years as well…and my best advice is to remember long term goals of sugars, vs the occasional random days of highs. Your doctors aren’t wrong for having more concern about the lows. They need to be addressed immediately, and can cause quick problems. The highs, if not having large ketones or lasting long, are part of the deal. We work hard to avoid them, but it’s not always going to happen. If time in range and A1C are showing good control, that’s what the doctors are going to be looking at.
Hope that helps a little

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Thank you for your reply and yes Karen your information is very helpful. This forum is great and so helpful just to hear others that understand! It seems our issue was the site because we’ve moved to using either of his legs and have been seeing much better numbers. I haven’t changed the carbs but did figure out the timing was off for breakfast. The carb ratio was set to 7 starting at 6 am and most school mornings he’s eating around 5:30. I changed it to 5am and he’s been in range more this week. We may need a different profile for weekends because he sleeps in and doesn’t get as much activity. We go back for our two week after pump appointment with endo Tuesday so I will ask about that then. Thanks again for the responses! God bless and prayers for all those effected by the tornadoes!