# position of cannula?



## heasandford (Mar 16, 2014)

Does anyone have a way of deciding where to put the cannula at each change? I change mine every 3 days, but have a really bad memory for these sort of things so don't remember where it was before the last time! I also have very little fat on my tummy, so only a relatively small area to work with. Do you move it up from down, or side to side or clockwise or...??


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## AlisonF (Mar 16, 2014)

I tend to work clockwise with 6- 8 different sets on my left thigh, same on right thigh, left and right buttock and stomach. By the time I get bcack to my left thigh a few months have passed so there's plenty of time for recovery.


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## Maryanne29 (Mar 16, 2014)

I wish I could reach round to connect the tube to the cannula in my buttock!


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## Sally71 (Mar 16, 2014)

We alternate sides, and then try to avoid anywhere that it's been recently (the marks take a couple of weeks to fade). Daughter doesn't like the idea of having anything in her buttocks but we might have to use them if we start getting lumps in the belly!  We try to use a wide area but it's hard sometimes, she doesn't have loads of fat either.


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## Pattidevans (Mar 16, 2014)

I found it most uncomfy using buttocks/back of hips.  I go up and down in lines either side of my navel, alternating sides and moving outwards when I have done bottom to top of that "line".


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## Pumper_Sue (Mar 17, 2014)

I start below ribs and work along the one side then go down to the next row until I reach the end of that side. Then start on the opposite side doing exactly the same thing.


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## everydayupsanddowns (Mar 17, 2014)

Pattidevans said:


> I found it most uncomfy using buttocks/back of hips.  I go up and down in lines either side of my navel, alternating sides and moving outwards when I have done bottom to top of that "line".





Pumper_Sue said:


> I start below ribs and work along the one side then go down to the next row until I reach the end of that side. Then start on the opposite side doing exactly the same thing.



I'm another that uses lines.

I've tried buttocks as a site a few times, but found it a bit lumpy when I was slouching back on the sofa - well more that I worried I would squash it/pull it out really.

I'm still using sides-round-to-back and to three lines on each side in a zig-zag pattern. Starting at the front just above waistband, moving around to about 2-3 inches from spine then back round to front again with a final return round to the back. I get 4 or 5 sites in a line so that's around a month before I return to the other side.

I probably should start looking for other sites too. But I've just kinda got into the habit. 

I have a much bigger area to aim at since I started using angled sets. The 90-degree ones seemed to need quite a bit of 'coverage' to avoid discomfort/set kinks.


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## heasandford (Mar 17, 2014)

I need to get myself into a routine of some kind, so some thoughts to have a go at here, thanks!
I once did a 'round the back' cannula which pulled out, so I'm not doing that again! Before pumping I found everywhere except my tummy was much slower to take effect, and since that's one of my problems I'm not using those areas at all any more


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## heasandford (Mar 17, 2014)

do you all get 4-5 sites per 'line'? I think I only manage 3 or so. Maybe I am afraid of them being too close together


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## everydayupsanddowns (Mar 17, 2014)

heasandford said:


> do you all get 4-5 sites per 'line'? I think I only manage 3 or so. Maybe I am afraid of them being too close together



I make sure the sticky pads don't overlap... but apart from that I try to pack em in!


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## novorapidboi26 (Mar 17, 2014)

I use my stomach and thighs and generally move round clockwise......

I always try to have my next canulla on the opposite side and stomach/thigh site as the one being changed...


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## Flower (Mar 17, 2014)

I used to be methodical and go clockwise around my stomach in ever decreasing circles in towards my navel but since using cgm I try and keep my cannula on the opposite side of my stomach to my sensor. This leaves me looking for any bit of me that isn't bruised or red and isn't at waistband level as I have pulled a few cannulas out catching on my clothes.


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## heasandford (Mar 17, 2014)

thanks everyone! I am trying to get the best out of being a pumper, some things not quite as I thought.


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## AlisonF (Mar 17, 2014)

Flower, have you tried wearing your cgm in your lower back? Mine lives there almost permanently, in various spots, always on the same side as my cannula which might be in my thigh, stomach or bum.


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## ingrid (Mar 18, 2014)

Good topic and useful replies! I'm nowhere near as methodical about site rotation as I know I ought to be. I'm not terribly keen on angled sets as I feel they leave a greater entry scar, but I can use them in leaner areas which wouldn't otherwise be used. 

I was at a pumpers educational afternoon at the hosp today (well...mutter, mutter...yesterday) and as I was the only Viber there, had a whole session with the Animas rep, as well as a little time with Roche rep (as I use their sets) and was informed that skinny children successfully use the steel cannulas in their sides/backs, so I'm reconsidering giving them a go for harder to access areas like butt. My previous attempts in bottom have all kinked! My reluctance is based on less flexibility of cannula when doing yoga, backed up with Patti's pain experience when first trying the steel ones!! But I keep being advised to give them a try. I suppose anything which increases available sites and/or set failures. 

Thanks for posting this topic


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## heasandford (Mar 18, 2014)

and thanks all for your useful replies!

I am still resistant to cannulas other than the one I started with, which is teflon and has an 'inserter' gadget. I really struggled putting in either of the angled or steel ones, drew blood, and haven't tried them since. Maybe I will have to, and will ask for help how to do it without closing my eyes!


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## everydayupsanddowns (Mar 18, 2014)

You may have seen this... but here are a few I tried...
http://www.everydayupsanddowns.co.uk/2012/09/set-changes.html

I found steel painless to insert, but a bit of a faff changing more frequently and with the double-sticky.

The silhouette kerplunker (angled sets for Veo) is a bit 'assertive' at times but I've got used to it and make sure I don't hold it too tight to the body when inserting.

Were there no inserters for the angled sets you tried?


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## Hanmillmum (Mar 18, 2014)

ingrid said:


> Good topic and useful replies! I'm nowhere near as methodical about site rotation as I know I ought to be. I'm not terribly keen on angled sets as I feel they leave a greater entry scar, but I can use them in leaner areas which wouldn't otherwise be used.
> 
> I was at a pumpers educational afternoon at the hosp today (well...mutter, mutter...yesterday) and as I was the only Viber there, had a whole session with the Animas rep, as well as a little time with Roche rep (as I use their sets) and was informed that skinny children successfully use the steel cannulas in their sides/backs, so I'm reconsidering giving them a go for harder to access areas like butt. My previous attempts in bottom have all kinked! My reluctance is based on less flexibility of cannula when doing yoga, backed up with Patti's pain experience when first trying the steel ones!! But I keep being advised to give them a try. I suppose anything which increases available sites and/or set failures.
> 
> Thanks for posting this topic



Hi Ingrid, we use the steel cannulas on my young daughter (back and buttocks) and there is no signs of any pain - she is comfortable bouncing around as usual and have been using these successfully from her being about 2 1/2yrs, she would definitely let me know believe me!!!! We had problems with Teflon kinking and have peace of mind with these. They are much quicker to administer (well for me doing it to her, may be different faffing around and twisting if you need to get it onto your bot and back) I believe this is the choice treatment for babies too. Worth a try. My only issue is you have to be extra careful on removal for reasons obvious.


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## ingrid (Mar 19, 2014)

heasandford - if you're happy with the sets you use, you don't need to change or even experiment, from what I've read on various lists the majority of pumpers do just stick with whatever they were first given and it works for them. In fact, when I requested to try some different ones, and even *gasp* sets from a different co. to my pump's co., my DSN was very surprised and didn't know about luer lock connections being the same on all pumps/sets except some Medtronic, and so interchangeable. I wasn't happy about various aspects of the Inset IIs (Animas) so needed to look to other co.s for what I was after (mostly manual insertion). Interestingly, there is only the option of manual insertion of angled sets with Roche and Animas. Medtronic are the only ones to offer a kerplunker (like that word, better than Sil-serter or whatever they call it!) for their angled sets. 

Thanks Mike for your blog ref. I'd forgotten about the double tape business...hmmm. And more frequent changing needed, though I might experiment stretching to every 3 days. I should still give them a try I think, and I'm very reassured now by your daughter's experiences Hanmillmum, thanks for that.


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## chandler (Mar 19, 2014)

Pumper_Sue said:


> I start below ribs and work along the one side then go down to the next row until I reach the end of that side. Then start on the opposite side doing exactly the same thing.



I do this too.  After both side of my front, I go round the back and fit a couple of rows on both sides, then upper buttocks but I find them difficult due to underwear waistband, belt on work trousers.  

Despite having more than sufficiently fat legs, thighs are tricky due to bending cannulas but I've had some success keeping towards the back of my legs.


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## heasandford (Mar 20, 2014)

everydayupsanddowns said:


> You may have seen this... but here are a few I tried...
> http://www.everydayupsanddowns.co.uk/2012/09/set-changes.html
> 
> Were there no inserters for the angled sets you tried?



Thanks for this link, I'd forgotten reading it! 

Accuchek angled cannulas don't have an inserter (kerplunker!). I don't think the ones I am using are a problem at the moment, but I will remember that I could use other makes, not just Accuchek, as they all fit


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## ingrid (Mar 21, 2014)

Hi all, been thinking about the steel jobbies today and trying to find out why they need changing every 2 days compared with 3 days for teflon? 

Tried googling, reading Pumping Insulin....recommendations and generalised reasons why sets fail but not a reason why the 48 hours need to change for steel. Any ideas anyone? 

There's this tunnelling effect which occurs if sets are left in too long but with short straight cannulas can't see that would happen much sooner with steel. Maybe body reacting to metal more quickly than teflon, but it's the insulin itself I thought which causes antibody build up or crystallisation?? 

I hate not knowing reasons why! And therefore what the risks are with pushing things to the limits (please don't tell me off anyone ;-) )


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## Pumper_Sue (Mar 21, 2014)

The reason the steel cannulas are changed every 2 days is due to scar tissue build up same reason as the tethlon is every 3 days. Different materials cause scaring at different times.


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## ingrid (Mar 22, 2014)

Thanks Sue. Do you think that it's because of the rigidity of the metal compared with softer give of teflon causing tissue damage more quickly? Even though they're very fine compared with teflon. As far as I can find out, steel is well tolerated (unless people have a nickel allergy as there's also some nickel in the cannulas), so it must be more than just the material itself?? I think I need to phone the pump co.s, problem is it's in their (financial) interest to recommend more frequent changes ;-) It's just odd that it's not that easy to find the reason behind the official recommendation!


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## Pumper_Sue (Mar 23, 2014)

Hi Ingrid, I doubt there's any financial gain for the company's as the steel cannulas are cheaper. Besides there no way the NHS would pay more for that option.
I did try the steel cannula and have to say after 2 days it was more than enough having it stuck in me. Personally I wouldn't want to risk going over the stated time of use as can not see the damage being done for the future.


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## ingrid (Mar 23, 2014)

Ha, at last I've found an up-to-date paper http://dst.sagepub.com/content/early/2014/02/26/1932296814523882.full 

including this gem of a paragraph (IIS = Insulin Infusion Sets) : 



> Length of use recommendations for IIS is generally 2 days for steel sets and 3 days for Teflon sets, although we are unable to find any data supporting these recommendations and at least one study found no difference.



I'm afraid the NHS is ripped off left, right and centre by pharmaceutical co.s, powerful lobbyists, undeclared interests, clever marketing, distorted and hidden trial results.....I'm not saying it is in this case, but I don't take anything at face value when I know the potential forces at play   

All I was really asking was whether anyone here knows what these 2 different recommendations for set change (teflon vs steel) are based on exactly, and what evidence there is for it (the difference)? As it stands, the different pump co.s recommend different lengths of time for both tubing and cartridge changes (at least Animas and Roche do, don't know about the others), presumably based on the same research evidence! 

I know in the end we also have to find out what works best for us, within the information we are given, or can access. But I would hope the starting point is based on sound well-researched evidence, and there just doesn't seem to be any regarding more frequent change of steel cannulas!! 

Gah....brain in overdrive. Thanks anyway for your input and thoughts


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## Pumper_Sue (Mar 23, 2014)

Thanks Ingrid, very interesting article. Personally I have no change in absorption between day 2 or 3 of cannula being in, and I for one do not want a foreign body stuck in me for more than 3 days. 2 days was more than enough for the steel sets anyway. I would also be interested to know the outcome a few years down the line if people don't change their sets regularly i.e lumps and bumps under the skin.


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## sacol4940 (Mar 26, 2014)

I do 3-4 on my right side, then 3-4 on my belly and then 3-4 on my left side

And repeat!


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## Maryanne29 (Mar 26, 2014)

I tried a new place for the cannula two days ago - I have limited places to use because of scarring and lumps and hollows caused by too many years on MDI. But it wasn't good. I've had results in double figures for two days despite changing the cannula after day one. I did a complete infusion set change this afternoon, went back to an area that has worked well before, and glad to say now back to normal results.


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## Pattidevans (Mar 28, 2014)

Just to throw a spanner in the works and add another variable!  I was told that once my vial was in use it was to be kept out of the fridge.  One thing I discovered a while ago is that insulin is light sensitive, so it can degrade if it's not kept in the dark once out of the fridge.  The second thing I have noticed is that whilst my vials are no way kept out of the fridge for more than 30 days, by the time I get to the 4th fill (I would normally keep a set in for 6 days with a cannula change every 3) that the insulin is decidedly less potent and I will be seeing double figures.  If I then change to a new vial it's like having a different and more potent insulin and I'll be back to single figs again.  I am experimenting with putting the vial back in the fridge in between set changes and only removing it a short time before a reservoir fill.  I'll let peeps know how it goes.

This may only apply to my insulin which is Apidra.


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## Pumper_Sue (Mar 29, 2014)

Hi Patti, I have never left my insulin out of the fridge. It comes out 30 mins before a refill is needed and goes straight back in again.
On my previous pump which had a bigger cartridge my insulin lasted at least 15 days with no problems. 

I have no absorption what so ever top end of bum or thighs so just use a very careful rotation for tummy.


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## Maryanne29 (Mar 31, 2014)

I still think my results are affected by temperature. I keep the current bottle out of the fridge, in its box in a drawer, so don't think it's a light issue. The first two days after a refill I get good results but after that they start creeping up and up. I have to refill every four days but change the cannula every two. I can only think the problem is caused by the insulin keeping warm next to me.


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## Redkite (Mar 31, 2014)

If it was the insulin warming up, you would have to refill every two days, not four.  So it is the cannula itself, or rather your skin/subcutaneous fat surrounding the cannula - it becomes irritated gradually to the presence of the cannula, and starts to absorb the insulin less well - my son has the same problem and also has to change every two days.


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