Troubleshooting

If managed correctly, problems with the pump are generally rare. However, when problems do arise, they can be incredibly frustrating. Below are some tips for troubleshooting the cortisol pump.
Please do not be discouraged! There are pumpers out there that have already encountered these problems and found solutions.
There are few potential causes for red itchy bumps at the infusion site, and in some cases, it may be difficult to tell which is the culprit.
Pump bumps are well known in the diabetic community and happen most commonly to people using insulin injections. These bumps may be caused by lipohypertrophy (Barola, et al 2018). Pump bumps are harmless though they can be annoying.
Pump bumps are known to somewhat inhibit the absorption of insulin, and from the anecdotal experiences of cortisol pumpers, it would seem this thickened tissue also hinders absorption of hydrocortisone as well. The absorption seems to decline the longer the cannula is left in the affected area. If you feel a lump at your infusion site, remove the cannula and start a new infusion site in a different location.
The more volume that is pumped through an infusion site and the more often an infusion site is used, the higher the probability of encountering a pump bump. This is yet another reason to rotate infusion sites and never use an inset longer than three days. Pump bumps do not usually require medical attention and will heal on their own. However they do tend to heal very slowly, sometimes taking weeks or months to fully heal. Avoid using this area until the lump is gone.
This is commonly referred to as a bleeder. Bleeders are caused by the cannula accidentally hitting a vein or the cannula damaging tiny capillaries under the skin. Knocking or bumping the infusion site can increase the chances of encountering a bleeder. Sometimes they seem to bleed an awful lot for such a tiny hole, but they are harmless. Bleeders do not require medical attention, but can be a mess to clean up.
Bleeders can sometimes be detected by bruising around the infusion site. Often this bruised area will not absorb hydrocortisone as well, and you might feel slightly “off” (fatigued, headache, etc.). It is a good idea to change your infusion set anytime you notice bruising.
With some experience, you can learn to be prepared for bleeders. If you notice bruising around the infusion site, blood in the cannula, red or dark dried blood around the adhesive, then you may have a bleeder to deal with.
You should always have a clean absorbent cloth, paper towels, or gauze handy when removing an inset. Also, you should have alcohol wipes to clean up any blood remaining on the skin, and a small adhesive bandage to place over the hole left by the cannula. Some pumpers also like to use an antibiotic ointment such as Neosporin on the hole left by the cannula before placing the adhesive bandage over it.
If your insets are not sticking well, or seem to fall off before you’re ready for a site change, don’t worry, there are endless solutions to help your inset stick.
Are you not falling asleep or waking up at the wrong times? Your basal program probably needs adjustments.
Both too much or too little cortisol can cause sleeplessness, making this a particularly challenging problem to solve. This is another reason having a 24 hour cortisol profile is a big advantage.
With 24 hour testing you will know exactly what your blood cortisol levels are from hour to hour so it is much easier to make accurate adjustments to the basal program that will allow you to get a good night’s sleep.
Please see the section “How Do I Know If My Basal Rates Are Adequate?” for more information.
If after starting on the cortisol pump you’re still dealing with daytime fatigue, it’s likely your basal program needs adjusting. Serial cortisol testing can provide the data needed to titrate your rates. In most cases it takes several rounds of serial cortisol testing to get the basal program set correctly.
Basal rates need to be checked periodically against serial lab work (at least once per year is suggested, or more frequently until the patient feels their best) in order to ensure they are still adequate. An individual’s cortisol requirement may increase or decrease over time depending on age, body mass, or other medications being taken.
Close attention needs to be paid to the early morning and AM peak cortisol levels. The pump is not like pills, the rates build on each other. Often in cases of daytime fatigue, the early morning basal rates are too low and consequently the AM peak does not reach an optimal level.
In some cases, the basal is programmed in such a way that the peak doesn’t occur until later in the day. Not only does this situation cause some over replacement, but as the entire day plays off of the AM peak, it is crucial to achieve the right level at the right time.
Please see the section “How Do I Know If My Basal Rates Are Adequate?” for more information.
Pumpers with non-conventional schedules, such as night shift workers, may need their peak time adjusted accordingly.
Sources
Barola, A., Tiwari, P., Bhansali, A., Grover, S., & Dayal, D. (2018). Insulin-Related Lipohypertrophy: Lipogenic Action or Tissue Trauma? Frontiers in Endocrinology, 9. doi: 10.3389/fendo.2018.00638