Issues with Medtronic MiniMed Revel insulin pump

 

A woman was receiving insulin from a Medtronic MiniMed Revel portable infusion pump. She began experiencing very low blood sugar (glucose) levels according to her blood testing kit. She reviewed the history of insulin doses on her insulin pump which saves information about extra doses that are given. In this case, the pump showed that the woman was getting extra doses of insulin during the night. She denied giving herself extra insulin at night. So, it was suspected that the woman had rolled over onto the pump while sleeping, putting enough pressure on the pump to release a dose.

Medtronic, the company that makes the pump, told us it has received rare reports of people accidently rolling over onto the pump at night, leading to extra insulin doses. A person would have to accidentally activate two different buttons for the pump to actually give a dose. There is a feature on the pump that needs to be enabled to lock out the pump's keypad so that this doesn't happen. The woman was shown how to do this, and, sure enough, the problem was resolved.

In another case, a man also had mysteriously low blood glucose levels while using the Revel insulin pump. In this case, it had nothing to do with accidentally pushing buttons to deliver extra doses at night. Instead, he entered the wrong information into the pump. The pump allows people to enter their blood glucose values and the amount of carbohydrates they have eaten. The pump then determines how much insulin is needed and administers a dose of insulin based on the values entered. By mistake, the man entered his blood glucose value (220) into the field intended for the grams of carbohydrates he had eaten (60). The value of "220" for a blood glucose is considered high, so the pump automatically delivered extra insulin doses to the man. The extra insulin doses caused the man's blood glucose to plummet.

The Medtronic MiniMed Revel insulin pump has a built-in blood glucose testing meter that requires special test strips. It is safest to use the blood testing meter that goes with the pump. This automatically communicates the glucose values to the pump so the information does not need to be entered manually. In this case, the man's insurance did not cover the test strips for the meter that goes with the pump, so he was using a different blood testing meter and entering the results manually. The pump will also warn you with a message on the pump screen when an entry is outside the usual range, but the warning message can be passed over. In this case, the man could not see the pump screens clearly, so he did not see the warning.

If you use a Medtronic MiniMed Revel insulin pump, be sure you are familiar with all the features of the pump. This includes how to lock out the pump's keypad to prevent extra insulin doses from being administered, and using the glucose meter that goes with the pump. For more information regarding the insulin pump, visit: www.medtronicdiabetes.com/customer-support/product-and-service-updates.

Created on September 24, 2014

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