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Scott Benner 0:00
Friends Hello, and welcome to Episode 530 of the Juicebox Podcast.

Jenny and I are going to talk about another diabetes variable today. And today's topic is called tunneling. But you may think of it as a leaky site. So I'm still deciding at the last minute what to call the episode. But once you get in here, you know, then you'll see the whole thing. Please remember, while you're listening that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, please always consult a physician before making any changes to your health care plan, or becoming bold with insulin. If you want to hire Jenny Smith, she works at integrated diabetes.com Check her out. And while I'm talking about stuff, let me remind you that I really appreciate when you share the show with other people. That's it, the show is growing incredibly fast. It is getting silly, silly amounts of downloads. And that is because of you. And I want to say thank you. So thank you very much for listening, for subscribing, and for sharing.

This episode of The Juicebox Podcast is sponsored by the Contour Next One blood glucose meter. In fact, the most accurate and easy to use blood glucose meter that I have ever used. Contour Next one.com forward slash Juicebox. Podcast is also sponsored today. By Dexcom, makers of the Dexcom g six continuous glucose monitor, you can find out more or get started today@dexcom.com forward slash juice box.

Jennifer Smith, CDE 2:05
Is the sound better? By the way? I guess you probably wouldn't be able to tell until you listened. But I I got a really long cord.

Scott Benner 2:14
Okay, and you're back in the other

Jennifer Smith, CDE 2:16
100 foot cord. And it's like out of my office down through our house down into the basement where the thing is. And so I'm back in my office small space. Right. So hopefully it won't echo is my show sound nice.

Scott Benner 2:33
Thank you. That was very nice. I would record you didn't have to buy Oh,

Unknown Speaker 2:36
god it was 20 bucks. Okay. All right. Deal. So yes, no, that's very nice. You're very kind to do that.

Scott Benner 2:44
Okay, so you brought up a topic, you sent me a note and you're like, you know, we should talk about tunneling. And I have to admit, I thought to myself, tunneling sounds like with those characters on Hogan's Heroes we're doing all the time when I was a little kid watching that show. And then I thought, well, Jenny knows I wrote it right on the list. And no lie. Four days later, I get a note, like an email, like something someone had to like, sit down and compose from a woman who said, Hey, could you and Jenny talk about tunneling? I thought, get out of here. Like, it's

Jennifer Smith, CDE 3:19
really funny. What works isn't like quite

Scott Benner 3:22
a coincidence. That's fine. So I don't know what it is. I'm just gonna be honest and say it.

Unknown Speaker 3:28
Really? Yeah. I

Scott Benner 3:29
mean, I, when you said the word, I started imagining what I think it is. I'm probably not far off. But I had never heard the phrase.

Jennifer Smith, CDE 3:38
So yeah, I mean, you're, you're probably not far off. I mean, you're a smart guy. So I'm quite sure that you can probably guess honestly, but it's most common with straight inserted Teflon infusions that's most common. It's really when the insulin that goes in through that infusion set or through the canula. And it's supposed to be get kind of dispersed under the sub q tissue absorbed, blah, blah, blah. It doesn't it sort of pools at that infusion site, and then because of that, it leaks back up. If you imagine the sides of the canula, right, it leaks back up the sides and it leaks out the top, so you're essentially losing insulin. So the most common are kind of the straight in infusion sets, especially the ones that are not very long, the shorter as well as it happens in larger doses. Typically, you're not going to see it in a dose that's like a unit. But if you've got pretty hefty donut boluses donuts, maybe I'm hungry. I don't know I ate breakfast this morning. If you've got pretty hefty boluses eight units, plus, you could potentially see more of That tunneling happening tends to be reduced in sets that are more the angled sets. Or especially for those who use the 90 degree set, if you can choose the steel canula, that goes straight in kind of like a foam tack, it doesn't tend to be as common to happen with that.

Scott Benner 5:22
So where would we see that? So I know on the pod goes in on an angle. And that's not the case. And I do know that people use like 90 degree sets that are plastic, and I've heard people say, Oh, if that one doesn't work, if the if the plastic handle doesn't work, try to steal one. Yep. Right. And well, so what you're making me feel like is, I don't know, has anyone ever, like, taken the garden hose and like, jammed it down into the mud, and then hold it there for a second, and then the water starts pouring back up like that. That's it. That's what's happening.

Jennifer Smith, CDE 5:53
That's exactly right. Yes. And, you know, it does also happen in more common, I guess, lifestyle types of activities that can be prone to like pulling, or yanking on the site, things like golfing, things like tennis, where you've got those swift movements, especially with tube pumps, that you can get that because anytime there is a yank on that tube, it Yanks the infusion set sitting under the skin. And another reason for tunneling is inflammation of that tissue underneath the skin. So as it gets inflamed, anything that gets inflamed gets puffy or swollen, right? And that creates more space. You would think if it gets swollen, it would create less space like it would squeeze the canula. It doesn't it actually creates more space expands. Yeah, right, it expands. And so the tube itself, the canula has more space to move, and insulin can leak that way as well. So

Scott Benner 6:58
we are counting on on some level. Anytime you put in an infusion set you're counting on so tenuous. Now that I'm thinking about it, you're counting on your body just sort of healing around that tube just a little bit to create a seal. Correct. And you start and so if you have a tube pump, the tubing gets pulled, that seal gets broken, if you're twisting or turning, it could get broken. And then you get what I would just call leaking. I didn't realize people called it tunneling, but like the site leaks is how I Right, right. Yeah, but that's specifically what's happening.

Jennifer Smith, CDE 7:31
It is exactly and you can tell, honestly, I mean Omnipod you can often tell because they do because there's insulin that kind of leaks around that edge. Or oftentimes you'll see liquid in that viewing window area. I mean, there should be some degree of condensation over the wear of a pod, not from me,

Scott Benner 7:53
do you know why? What do you do? What's your magic. So after I pop the little plastic, like safety tab off the Omni pod, we take a clean tissue and twist it like and we we dab the liquid

now people listening just heard of very weird diabetes like nerd that moment. Because if I take the liquid out that I can trust, if I see liquid in the window, that sounds coming from the site,

Jennifer Smith, CDE 8:27
right? Because you can usually tell liquid versus again, condensation, I mean a really hot sticky day or if you're sitting in a sauna or something like that, you may get some visible like clouding condensation in that viewing window. But it shouldn't be liquid to the degree that you can physically like see it almost if you've ever had like a bloody sight, you can see the blood sort of pooling in that area. It's the same thing with tunneling of insulin. And on the pods, I've, I've noticed more than with tube pod to tube pumps, that that adhesive that's right around that curved area. If you've got a leaking problem, it's going to be wet there too. Let's face it, it's Yeah. Um, so I mean, some ways around it are for those who are more active or have more movement to their day, or just kids who are just more prone to pulling on a tube pump, potentially. I mean, there are some tricks things like using the product called iv 3000. It's like a really thin, clear sort of bandaid, almost hypoallergenic, you put it down on the skin, you essentially put the site over that and let the canula go in and through. And then you put another one on top of it almost sandwiching the infusion site, so that what happens is you minimize like the movement, okay,

Scott Benner 9:50
so like there's no tectonic shift, sort of like that. That's correct.

Jennifer Smith, CDE 9:55
Yeah, the other one is and this is actually with and maybe Part of the reason that it's better with steel camulos is that the steel Canyon has a site. And then it has a short amount of tubing that connects to another, not a site, but almost like another little adhesive area. So you've got the site tubing, a site that holds that secure, and then the tubing that goes on from there. So another recommendation with non steel cannulas is to just take about a two to three inch section after the canula and adhere it to the skin using some type of you know skin.

Scott Benner 10:40
Okay, so if you're if you're using tubing, you go a couple inches away from your site and here the tubing to your skin. And that way pulling on the tubing pulls on the fixed site, not on the

Jennifer Smith, CDE 10:50
not so much on the actual infused area.

Scott Benner 10:53
Yes. Is this more common in certain body styles or types or older or newer sites or anything like that.

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Jennifer Smith, CDE 15:06
Definitely, I mean, you bring up a good thing about, you know, just the rotation of sites, obviously, because if that is going to be a reason for tunneling, older sites, sites that have more scar tissue, again, scar tissue is going to be less mobile or less, you know, flexible, I guess is the better word. So you're going to have the tissue that's hard, and has more ability for that canula to kind of have wiggle room.

Scott Benner 15:34
Alright. But not like I'm thinner, I'm heavier, I'm older, I'm young, none of that stuff happens.

Jennifer Smith, CDE 15:40
That doesn't seem to be it's much more the insulin amount, and then the movement itself of that particular person's lifestyle.

Scott Benner 15:50
So if I just sit perfectly still, I'll be okay. And don't eat a lot of food don't eat the Bolus. So you're saying if I could just basically get rid of diabetes, and this tunneling thing wouldn't be much of an issue at all.

Jennifer Smith, CDE 16:02
Right? I mean, in terms of in terms of the insulin doses themselves, knowing that we obviously have to use insulin. Sometimes using the fancy features on a pump can be more beneficial to dispersing insulin slower. So using things like an extended Bolus with a portion of a large Bolus, now a portion extended out a little bit more slowly. I know some of the insulin pumps. I know tandem does it. I can't remember I don't think that Medtronic allows you to change but tandem allows you to change the rate at which your insulin gets dripped and on boluses. And so slowing that process down even in a small amount can sometimes help that Bolus get absorbed. I've

Scott Benner 16:51
often used a 30 minute extended Bolus to bridge a gap like while Arden's leaving a class going to lunch like if like if her blood sugar 78. And I still want to Pre-Bolus but I'm like, Well, I don't know how we're gonna do this. Like I can't put it as much as I want, because she's going to be low before she eats, right? I would do like a 0%, upfront, and all over 3030 minutes. So you kind of get it in on time ish. But it's not all in there that seems like that might help that, hey, this is making me wonder do people with higher basil rates, Basil? How do I just miss pronounce basil to people with higher basil rates? Go through this more often. Do you think

Jennifer Smith, CDE 17:33
like we would expect? So I mean, I would say yes. In general terms, yes, mainly, because if you've got a higher basil rate to begin with, you also have much larger boluses. I mean, think about a Basal rate that's like 1.75, you're not going to have an insulin to carb ratio of one to 30. And if you do there, something's not set. Something's wrong. start over again. But you would expect that with larger basil, overall, your sensitivity to insulin is lower. So you're going to need larger Bolus as well. So another thing that kind of goes along with decreased chance of tunneling, especially with larger insulin dose, is making sure that you're changing the site more frequently, okay, you might need to change the sight, despite your pump holding 300 units of insulin, you might need to change it once you get to two full days, and nothing beyond that, regardless of the amount of insulin, you know, in that large amount, you might make it to two days. And that might be it.

Scott Benner 18:33
Could you cheat a little and split your Bolus, and inject some of it, if this was an issue,

Jennifer Smith, CDE 18:38
you're kind of getting into all the realm of what I do in pregnancy with women who've got really high resistance before they get pregnant. And we know that their insulin needs are going to be just exorbitant by that third trimester, we pull a lot of tricks out of a hat, I mean, we sometimes cover 50 or 60% of the basil with a basil injected insulin and take the basil that's pumped in way down, then we may even use you 200 insulin, which gives you two units of action per one unit of an actual dose volume. So then instead of a Basal of two, you get down to a Basal of one, but you're getting the impact of a Basal of two. What is that called?

Scott Benner 19:19
I can't think of the word all of a sudden when people only Bolus with their pumps, but they use an injected Basal insulin. They call it something

Jennifer Smith, CDE 19:28
really, I don't know the name for that. But it's

Scott Benner 19:30
right out of my How could two people who twist up a tissue and dad out the couple of drops of insulin on the pod not be able to remember that word?

Jennifer Smith, CDE 19:39
I don't know what that's called.

Scott Benner 19:40
I'm never gonna figure it out sitting here, that's for sure. But But people have a name for it.

Jennifer Smith, CDE 19:45
They do and even at smaller doses, some people find that for whatever reason, a Bolus with an injection works a lot better they get more very precise. Like dosing action. Yeah. And impact of action by just Taking a Bolus versus they love the precision of the basil coming from their pump. Okay, so I mean, there are lots of ways to attack things. Definitely. I've got someone in college right now that I work with and she knows that any Bolus that she needs to take over seven units, she will have tunnelling, if she doesn't Bolus with an injection,

Scott Benner 20:21
okay, would change into an omni pod for her make a difference? She's on Omnipod. It's still happening to her even with the FC that so some people it's funny because you hear people sometimes say, oh, if you're having trouble with that with the, the Omni pod can yell at go to a pump with a 90 degree candle. And I've heard people say, Oh, if this 90 degree candle is not working for you, you should try the army. Right? Exactly. Right. You shouldn't just sit around struggling with something that doesn't work for you.

Jennifer Smith, CDE 20:48
No, you shouldn't. And that's a that is one benefit, I think to tube pumps is that if you think it's one canula that you're using, there are multiple to choose to try. Call the company and let them know hey, I think that this set this type of set is a problem. Do you have some I'd like to try this one. This one, they'll usually send you a couple of samples to try before you order a whole big box.

Scott Benner 21:11
years ago, I interviewed Todd Hobbs, who I think at the time was the CEO of Novo Nordisk, but I don't, I don't believe he is anymore. And in his talking about what he thought people with type one diabetes needed, he was adamant that what they needed was better canula technology. Oh, yeah, that at the top of his list, you know,

Jennifer Smith, CDE 21:32
well, and there, I'm sure that you've seen, the study is about the candle that has, it's almost like a sprinkler effect, right? It's a candle, that's a tube that's got multiple holes through the tubing rather than just coming out the end. And what they find is that with more more surface area that they're covering with like a spray of insulin, rather than an injection, at one point, you get a lot better absorption, you get more precise and even absorption. And tunneling almost disappears.

Scott Benner 22:04
I wonder how hard that is then to inject the cannula because now maybe some of the rigidness of it is gone? Because you've got little holes in the side. Right? Good question. Yeah. All right. What made you want to do this? Like why you were very like, like, we talk frequently, but not that frequently. And you were like, Hey, we're doing this.

Jennifer Smith, CDE 22:26
Yeah, because I think in and I, you know, I texted you about it as like one of the variables, because we've got so many variables to talk about. And I think a lot of people call it leaking. Right? Without, and I think it helps to understand what's actually happening. And some of the reasons and the frequency if you're one person versus another, you know, one kid who's like, a swimmer maybe has no issues ever with tunneling, and they're the same body size and type of their, their little buddy next door, who is an avid golfer? Well, there might be the issue to consider, you know. So I think I think I thought it was important, because I don't see a lot of people but I see enough people that have had this issue. And just think that they've done something wrong, or their doctor isn't offering any solution. I don't know it's a leaky site, change it?

Unknown Speaker 23:21
Well, yes. But

Scott Benner 23:22
it'd be nice if I understood this a little better. It's funny, because he's, you said that, I thought, well, I'm gonna have to call the I'm gonna have to call the episode leaky site so that people even understand like, how to go, like, figure out what it is right. But that's great. I'm glad you did this.

Jennifer Smith, CDE 23:39
Awesome. Yay.

Scott Benner 23:47
Jenny and I are starting to get quite a little list of diabetes variables, episodes. You can find them right there in your podcast player. There's a lot more just search Juicebox Podcast, diabetes variables, or search diabetes variables at Juicebox. Podcast calm. When I get a couple more together, I'm going to build a list. But Ilana put it on the website. Not quite yet, though. Come come into it. All things in time, my friends. Are you looking for Jenny? She's an integrated diabetes.com. Oh, and let me thank the advertisers. Thank you Dexcom, makers of the G six continuous glucose monitor. And of course, the Contour Next One blood glucose meter.

Why I almost forgot the links. I think they pay me to say the links dexcom.com forward slash juicebox. Contour Next one.com forward slash juice box. Check out that amazing Dexcom g six, and the most accurate meter I've ever held. The Contour Next One. Thank you so much for listening. Thank you for sharing the show. Thank you for downloading it your podcast app. Oh, Thank you for subscribing in your podcast app. Thank you. Thank you. Thank you. Thank you. Thank you for making the Juicebox Podcast what it is, I really appreciate it every time you listen every time you share, every time, everything. If you're really looking for some help with all this stuff, you should check out the private Facebook group for the podcast. It's called Juicebox Podcast, type one diabetes, and there are over 14,000 members. I do my best to look in on it every day. And so should you it's an incredibly helpful Facebook group. I know that sounds kind of weird, like people like Facebook doesn't Facebook suck. Maybe it does, but not this group Juicebox Podcast, type one diabetes, go find your brethren. They're very, very kind, very helpful and excited to say hello to you.