# Bubbles



## treasure_ireland (Mar 6, 2011)

Hi all,

Every time I look at the cartridge in my pump I always seem to see a sneaky bubble, even though there wasn't any after I primed.

Any ideas how they have appeared? Or any tips to stop this happening?


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## Ergates (Mar 6, 2011)

I think it's dissolved gasses coming out of solution.  I've got rid of most of mine by using insulin that's been at room temp for a few hours, and then loading the cartridge and leaving it out again for a few hours or even overnight.  You can then tap most of the bubbles out, although you'll still get some inside the cartridge again after a few days.

My pump is hung around my neck with the cartridge pointing downwards, so any bubbles rise to the plunger and hopefully don't get in the tubing.


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## treasure_ireland (Mar 6, 2011)

As soon as iv emptied a bottle, I get new one out of fridge, so it's been at room temp for ages.

Yet again when I put new cartridge in new pump, I get a new one ready for next time.

Im trying to avoid them but not working.

Mines on my waist, feel like I'm scared to jump incase more appear.

Weird thing is iv never seen any in line, but don't want to hence me trying to prevent it


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## Adrienne (Mar 7, 2011)

Hiya

Some people get bubbles, some don't.  I'm not going to be Mrs popular by saying this, but I'm going to say it anyway, it is practice practice practice ie technique.   So many people ask this and it is purely technique.   Like you when one insulin finishes I get the next vial out the fridge and it stays out the fridge for 4 weeks.  I don't draw up in advance, something about insulin not liking being in plastic and sticking to it or something, so not sure that is a great idea if that is done a day or so in advance.

I get a few bubbles in the reservoir and just tap them out, you can flick with your finger or use something to tap the side with ie a pen, just flick away and then push the top bit through the tubing before priming it out.  

My daughter wears her horizontally in a pump pouch around her waist and as a child she jumps and bounces (alot) and I think our last bubble was probably 2  years ago maybe more.   

So you'll get there and you won't get bubbles.   

Ok now I'll go run and hide with the others that have to go and run and hide


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## Liz! (Mar 7, 2011)

bubbles happen - temperature can play a part, even if it was just water in there bubbles would form as oxygen leaves the water because of differnces in temperature. 

You can help by taking insulin out of the fridge so it is room temp before you draw it up, but that doesn't help if there is a change in temperature while it is in the syringe. 

You can also push the air from the cartridge into the vial when it is upright, ie into the part of the insulin vial which has air in, NOT INSULIN. Then turn it upside down and draw the insulin out. That way you are not bubbling air through the insulin. This helps. 

You're never going to stop them all, depending on what you are doing.


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## Adrienne (Mar 7, 2011)

Liz! said:


> bubbles happen - temperature can play a part, even if it was just water in there bubbles would form as oxygen leaves the water because of differnces in temperature.
> 
> You can help by taking insulin out of the fridge so it is room temp before you draw it up, but that doesn't help if there is a change in temperature while it is in the syringe.
> 
> ...



Plus draw it up slowly, really really really really slowly.  The slower the better.


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## Jennywren (Mar 7, 2011)

Dont bubbles drive you crazy !!!!!!!!!! I can have no bubbles but when i attach tube there appear , so i think its when you attach the tube .My husband is pretty good and patient with the bubbles ,he gets them all up the top and will prime the cartridge until the bubbles come out .


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## Ergates (Mar 7, 2011)

It's not too hard to avoid getting bubbles in the cartridge via the drawing up, but it's just about impossible to avoid the small bubbles that form later as a result of gas coming out of solution.  It's also not too hard to get them out the tubing when you're aware that happens.

I'm not sure whether preparing the cartridge a day early would matter - when it's going to be in the pump for 6 days or so anyway, and when the pump company suggest to prep the next cartridge as soon as you install the first.  If insulin didn't like being in plastic enough to matter, surely cartridges would be made out of something else?


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## Pumper_Sue (Mar 7, 2011)

Ergates said:


> I'm not sure whether preparing the cartridge a day early would matter - when it's going to be in the pump for 6 days or so anyway, and when the pump company suggest to prep the next cartridge as soon as you install the first.  If insulin didn't like being in plastic enough to matter, surely cartridges would be made out of something else?



There is no way you should be drawing up a cartridge 24 hours before you use it 
The cartridge has a a lubricant in it to make sure it moves smoothly.
Are you 100% sure that you have not pulled the plunger right to the end and let air leak in around the seal?
Are all connections secure?
If all the above are correct then if it's a Roche pump I suspect you will have to put up with it as it's mainly people using them that complain so I do wonder if a design fault 
Otherwise it's down to the way you are filling the cartridge.
Keep insulin out in a store cupboard away from light or take from fridge at least 20 mins before use. Fill slowly, tap out any bubbles that can be seen. then leave cartridge to stand for 20 mins and tap out any small bubbles with a pen or flick with finger.
I'm another one who has never had any problems with bubbles.
I have a Cozmo.


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## Ergates (Mar 7, 2011)

Pumper_Sue said:


> There is no way you should be drawing up a cartridge 24 hours before you use it



Are you sure, and why?  It's not what Roche say.  Neither is the taking the insulin from the fridge 20 mins before.

I don't have any problems with bubbles, btw.  I was simply sharing my strategies for avoiding them.  I have no trouble at all avoiding drawing air into the cartridge,and there's definitely no air leakage as you're suggesting.

You don't get any small bubbles as a result of gas coming out of solution?  I'd be quite surprised at that.  The difference between bubbles of air drawn into the cartridge, and the much smaller bubbles of gas from solution is very obvious, by the way.  They're not hard to deal with either.


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## Adrienne (Mar 7, 2011)

Pumper Sue is right everyone.  You should not be filling up a day or so early.

One other query I have, someone said about it being in the pump for 6 days? How come so long.  It is recommended to change every two days but people generally do 3.   Not sure about leaving insulin in the reservoir or tubing for that long.  Its about crystalizing or something, not sure but could find out.


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## Ergates (Mar 7, 2011)

Again, that's not matching what Roche say, or rather what their sales lady told us, and what the DSN mentioned either [1].  I'll call them and check shortly.  How about you guys check for quotes from your manuals and report back?

I know that they tend to supply me with 1 box of cannulas and one box of cannula plus tubing as they expect that you'll use two cannulas (each stays in for 2-3 days) for every cartridge and tubing set change.

[1] Assuming I remember correctly the DSN was quite happy with the idea of doing a cartridge a day early, but was less keen on the Roche sales lady's mention of preparing the next cartridge immediately after installing a new one.


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## Pumper_Sue (Mar 7, 2011)

I only put in enough insulin to change my cartridge every 6 days.
If I filled it up then it would last 12 days.
But know 6 days is ok to have insulin in the cartridge. I have left it 8 days and that did cause it to precipitate so 6 it is for me to be safe.


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## Ergates (Mar 7, 2011)

Roche Technical Support just called me and confirmed what I've posted above.  The chap went further, to say that it'd be fine to prep up three cartridges from a 10ml vial of insulin and then keep them in the fridge.  That could mean the final cartridge has insulin in it for as much as 18 days in total by the end of use in the pump.


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## Pumper_Sue (Mar 7, 2011)

Ergates said:


> Are you sure, and why?  It's not what Roche say.  Neither is the taking the insulin from the fridge 20 mins before.



Yes 100% sure as stated in my previous post there is a lubricant sp* in the cartridge which allows the cartridge to move freely so you do not want your insulin sitting in this for 24 hours for starters and this also would cause the lubricant to not work I suspect. My pump rep told me this and it is well known NOT to fill the cartridge 24 hours in advance.

The reason for taking the insulin out of the fridge 20 mins before is to bring it up to room temp, this again causes less bubbles.

Mind you Roche told me certain types of fast acting insulin couldn't be used in their pump either. So what they say I take with very large bucket of salt


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## Pumper_Sue (Mar 7, 2011)

Ergates said:


> Roche Technical Support just called me and confirmed what I've posted above.  The chap went further, to say that it'd be fine to prep up three cartridges from a 10ml vial of insulin and then keep them in the fridge.  That could mean the final cartridge has insulin in it for as much as 18 days in total by the end of use in the pump.



Well there you go perhaps that's why so many people have so many problems with blockages and bubbles with a Roche pump then


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## Liz! (Mar 7, 2011)

I know there is a lubricant on syringes wwhich is why you are supposed to 'pump' the syringe up and down to get it moving freely before putting insulin in. My insulin is in my cartrdidge for 3 days. Some hve it in for 4 days. So how 24 hours longer could it make much more/any difference?


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## Ergates (Mar 7, 2011)

Liz! said:


> I know there is a lubricant on syringes wwhich is why you are supposed to 'pump' the syringe up and down to get it moving freely before putting insulin in. My insulin is in my cartrdidge for 3 days. Some hve it in for 4 days. So how 24 hours longer could it make much more/any difference?



Exactly.

Folks, if you're going to dispute what at least one manufacturer says, as well as a DSN, at least lets have some supported quotes from your pump documentation or your own manufacturer please.  Otherwise it's all FUD (fear, uncertainty, and doubt).


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## Ergates (Mar 7, 2011)

Pumper_Sue said:


> Yes 100% sure as stated in my previous post there is a lubricant sp* in the cartridge which allows the cartridge to move freely so you do not want your insulin sitting in this for 24 hours for starters and this also would cause the lubricant to not work I suspect. My pump rep told me this and it is well known NOT to fill the cartridge 24 hours in advance.
> 
> The reason for taking the insulin out of the fridge 20 mins before is to bring it up to room temp, this again causes less bubbles.
> 
> Mind you Roche told me certain types of fast acting insulin couldn't be used in their pump either. So what they say I take with very large bucket of salt



Yes, I'm aware of the lubricant.  It's not my point though - if you're OK to have your cartridge in the pump for 3 days, why not 24 hours before?  I don't see how keeping the cartridge in your pump is any different to keeping it out of your pump.

Secondly, I'd argue that 20 minutes is not long enough to leave between taking your vial out of the fridge and filling your cartridge, and that a few hours is what is normally recommended.


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## Ellie Jones (Mar 7, 2011)

Bubbles!

Some of it is purely down to technique, some is down to chemisty of how oxegen reacts within a liquid at verying tempretures!

I find that ensuring that when carrying insulin from storage area to filling area that ensuring vial isn't shaken (tend to take and leave my vial on the table for a hour or so before filling) and being gentle when turning to draw the insulin!

I always fill my cartriges full and use them for 16/17 days I haven't ever had any problems with this, with an exception on a couple hot weeks and it's gone off slightly near the end of the cartridge..

Rouche pumps don't suffer any more with bubbles than any other pump, the pumpers list did a survery concerning this and transpired that the assumption that Rouche pumps suffered more than other manufacturers was actually a myth..  No pump came out better or worse when it came to bubbles!  Other findings also suggested that insulin type didn't play a part either...  But technique and temperture flutuations did seem to have an impact on the occurance of bubbles..


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## treasure_ireland (Mar 7, 2011)

Hi Ellie Jones,

Thanks for this.

My friend mentioned de-gassing to me, but I'm unsure what she means.

I just do it the way the Roche rep taught me & how the manual said.

I do draw up a vial straight after putting in a new one, which has now got me worried, as it will stay out for 6/7 days.

Nice to know from that survey that Roche pumps arnt as good as others also.

Thanks


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## shiv (Mar 7, 2011)

^ there's a good video of an American girl degassing a vial of insulin on youtube, have a search for it!


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## Pumper_Sue (Mar 8, 2011)

> Rouche pumps don't suffer any more with bubbles than any other pump, the pumpers list did a survery concerning this and transpired that the assumption that Rouche pumps suffered more than other manufacturers was actually a myth



That was not a proper survey at all, just one forum member that asked half a doz pumpers.


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## Ergates (Mar 8, 2011)

shiv said:


> ^ there's a good video of an American girl degassing a vial of insulin on youtube, have a search for it!



This one?

http://www.youtube.com/watch?v=OwbelFCNGz4

That's quite a good idea to lower the pressure in the vial to draw gas out of solution.

I'd agree that a couple of questions doesn't a survey make, but I suppose that applies equally well to the myth that Roche pumps experience more bubbles.  Of course it's unlikely to be the pump causing the bubbles, rather the cartridge used.    I imagine it's more likely to be related to technique than any specific manufacturer.

No matter though, I don't have a problem with bubbles either.


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## shiv (Mar 8, 2011)

I'm only a few months in to pumping, and I find that sometimes I can draw up a cartridge perfectly in one go, and other times it takes a few attempts.

One thing I personally find helps me is the opposing to degassing (so I guess gassing?!) - having the vial the right way up, pushing air into it, then turning it upside down - it just pushes the insulin straight into the cartridge. I dislike degassing as I find I end up having to pull quite hard on the plunger (maybe I'm degassing too much?? hmmmm) which causes its own problems!


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## Ergates (Mar 10, 2011)

Well that degassing is teh bomb!  No microbubbles formed overnight at all on a cartridge I drew up yesterday.


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## Adrienne (Mar 11, 2011)

Hiya

I asked Medtronic about filling reservoirs before and how long should you keep insulin in the reservoir for and bubbles etc etc.  This is their reply :

"The reservoir and tubing should both be changed every 2/3days (depending on set used). This prevents deterioration of the Insulin, potential occlusion within the set or reservoir and potential site infection which can then cause scarring. Pre-filling is not advised by Medtronic mainly due to gassing of the Insulin, we recommend the insulin is warmed to body/room temperature before drawing up as once within the reservoir should Insulin increase in temperature it will gas causing bubbles in the tube.  

We see many issues of bubbles in tubing and the majority are to do with Insulin at incorrect temperature when drawn up, especially for ladies who wear their pump in their bra, in these cases we recommend warming the insulin to body temperature and not room temperature as when the pump is stored close to the body the temperature of the Insulin will rise from room temperature to body temperature causing gassing.  

We regularly see air bubbles with pre-filled reservoirs especially when they have then been stored in the fridge.  More importantly we see "no delivery" issues with sets used for longer than 3 days, even a 4th day can have an effect on the insulin and cause potential problems.  

One other point to remember is that when drawing up insulin the vial can become over pressurised and we recommend decompressing from time to time as the volume of air in the vial increases.  This is done by detaching the reservoir from the blue needle housing following the drawing up of insulin, by leaving the needle housing in the vial this will give the bottle a chance to equalize air pressure.  If this is not done air pressure from within the vial can build up and causes tiny (not seen) bubbles within the insulin drawn into the reservoir, these then over time group together to cause a larger bubble. On these occasions a patient may feel they have done everything correct when drawing up insulin, but have not appreciated that the insulin in the vial which is under pressure from the insertion of excess air when pressurising will case tiny, tiny bubbles to occur in the insulin when it is drawn up under excess pressure.

I have attached our set guide which includes the US Centres for Diabetes Control and Prevention guidelines on set changing.

 So for best practice to ensure correct delivery we advocate:

Change reservoir and set every 2/3 days.
Do not pre-fill reservoirs.
Warm Insulin to body/room temperature.
Decompress the insulin vial."

If anyone wants the set changing guide pm me with your email address and I'll send it to you.  It doesn't yet include the MIO though.

I think this makes it clear where Medtronic stand on things and this is why some of us using Medtronic keep to these rules.  We have no bubbles at all and we use these rules.   

Hope that helps.


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## Ergates (Mar 11, 2011)

I'm using a Roche pump, and follow the Roche guidelines, and I don't suffer from bubbles either.


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## Twitchy (Mar 11, 2011)

*Bubbles - definition of 'hand tight' luer lock! )*

Hi! I had loads of problems in the early days with my accu check combo & bubbles (think I put a thread up about insulin 'mousse'!) Basically I had read the manual religiously & had seen the instruction about not using the battery / luer lock key to tighten the luer lock up (The luer lock being the connection between the tubing & the pump - the key is only supposed to be used to undo the luer lock if it's too tight).  I'd been tightening the lock up by hand as tight as I could manage, but apparently my version of 'hand tight' doesn't cut it!  Now I use the key (per the dsn's original instructions, doh! ) & just tighten very carefully, being careful not to overtorque. Since I've done this, I've not had any major problems with bubbles, phew! 

(I also have a bottle of insulin in my 'pump spares' bag that lives in my hand bag - i refill from this when I need to do a set change. I sometimes run the plunger up & down, but not every time! Drawing up slowly, carefully tapping up any bubbles seems to help too...)

Best of luck!


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## Adrienne (Mar 11, 2011)

Twitchy said:


> (I also have a bottle of insulin in my 'pump spares' bag that lives in my hand bag - i refill from this when I need to do a set change. I sometimes run the plunger up & down, but not every time! Drawing up slowly, carefully tapping up any bubbles seems to help too...)
> 
> Best of luck!



Yep I do that exactly as well


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