Yikes, that’s a little off – at least in my case.
If Liam is below 80 (which I don’t consider low…I consider 70 as low), and if I treat him with 15 unboluses carbs, his BG would skyrocket to over 250.
The test for ketones, I’ve been of the understanding that the threshold for testing ketones is 240! Not 151! I would be in the poor house if I checked Liam for ketones everytime he went over 151 (most of the day).
Somehow I think that particular flowchart isn’t accurate?
This is nice! And this is in line with what I do normally w/o ketone checks also. When he’s elevated too long, I always give a little more than I usually would (10 - 25% more sounds about right also.)
You are quite right. A guide only–and a general one at that. We still have to take “tests” to make sure we know this information even though we don’t use it exactly. Obviously everyone is different, but the general flow makes sense.
The worst situation is when he is low, can’t get his BG to come up AND has ketones. Basically if this happens too long, it will lead to hospitalization with IV. Micro-doses with glucagon are an option, but I personally haven’t had to use that yet (although very close to it).
I hope I NEVER run into this. Lows that refuse to come up are so scary. Liam has had lows before that didn’t come up even after FIVE sugar tablets! Then…45 minutes later he skyrocketed to over 300. 
Those times are scary as hell.
Yea, usually happens with a stomach bug. It is so unpredictable and has lasting effects. My son actually went a week after a stomach sickness with 0 boluses. Even though he had been eating lots of carbs (pancakes with syrup, ect). The first bolus before we figured this out was quite scary.
@ClaudnDaye, so in this situation, what I would *ideally do versus what my *sleep-deprived brain might tell me to do are different.
Ideally, I would
a) check his pump site, make sure he’s connected, that the pump is not suspended, and that there are no visible occlusions
b) disconnect and prime (not sure you can do this with OmniPod) to make sure any hidden bubbles are removed
c) check blood ketones – he gets so little insulin at night that if he’s that high, it’s possible he could be generating a lot f ketones.
d) if he has high ketones, give a correction PLUS a bump for the ketones
e) refill his water glass or water bottle so that he can wake up to drink it at night.
f) often I’ll give a manual correction with pen, then give the *same bolus from the pump with him disconnected so I can keep track of IOB.
Sleep deprived I might do as you do – give a correction bolus and roll back to sleep, especially if he ate something like ice cream plus pizza plus breadsticks or something, where I suspected he’s going to run high if I don’t keep ahead of it.
The problem with this approach is that in our experience ALL the times Samson has generated high ketones have been overnight when his pump was suspended or unplugged, or the battery in it died. And it only takes 3 hours to start being ketotic if you have no insulin flowing through your system. So if he’s high for 3 hours, that’s a warning sign to me.So I see nighttime as an inherently riskier time for DKA to develop. Also, because we have openAPS, it has already been piling on insulin at night, so if he’s not coming down, that’s suspicious.
So when I see a high BG number at night, I see it as a riskier then when he’s awake and can both tell us he feels sick AND has more stuff going on, insulin wise (such as boluses), where we’d notice pretty quick if his pump was just not working.
Even on my sleep deprived nights, I would never go back to sleep until the sugars are back down, if he’s been high for any prolonged period of time. If that means I’m up the rest of the night, I’m OK with that. I never bolus and go back to sleep when he’s high…for the very reason that I want to verify that my correction is working. If I go back to sleep I won’t know if my correction is doing anything at all.
I do agree with you that nighttimes are ALWAYS inherently more risky since our eyes aren’t constantly looking at the BG level (in my case, every 5 minutes or so…yes, I am OCD). So when/if we run into a case where we find him high and he’s not gone down for X number of hours (we’ve never had 3 hours of prolonged highs over the night, but we have had 1 to 2.). In these cases (even if I was dead to the world minutes before), I’ll wake up and sit up until his sugars go back down…I have to know that my correction worked OR I have to be awake to take further corrective action as necessary.
The other point i’d make is that with your protocol, you run the risk of letting the ketone generation go longer – probably 4 to 6 hours, rather than 3 – and then, while it’s unlikely to turn into full-blown DKA, you’ll have at least an additional four or five hours before the ketones have cleared…so in those events you wind up with a long, long day of crummy blood sugar management ahead of you.
Do you not trust your alarms to waken you after, say, 30 minutes if he’s still high and not dropping, or if the correction was too much and he goes low?
How so? I don’t think you understood my protocol correctly possibly?
No, I don’t sleep…that’s what I’m saying. If he has a prolonged high that I had to correct and that high hasn’t come back down, I just don’t sleep. I stay awake, watch TV and check his BG and correct more if I have too. I don’t sleep until he’s landed safely back down and I ensure he doesn’t crash from the extra insulin I’ve had to give him.
well if he’s been high for 3 hours, as in your example, and then you give a correction, you have to wait a minimum of 45 minutes or so to see how much it’s working, if at all. At that point, if it’s not working, and you do check the site, and let’s say it’s bad, then you check ketones, he’s had at least an additional hour of being high and generating ketones, which means he’s likely at a higher level of ketones. And that takes longer to clear. The ketones can often still be high for hours after the BG numbers go down to normal – we’ve had Samson be “LOW” on Dexcom but with still moderate-to-high ketones.
ETA: So this example was what I was referring to:
I have been sleeping, and slept through “high” alerts. I woke up at 4:30 when I finally noticed that his CGM reads 278 so I do a BG check and find that he’s 289. I also observe that he’s been above 250 since 1:30 (3 hours).
I get what you’re saying…so you’re saying a site check should be the first consideration. I can certainly understand that and I will definitely make sure I do that in the future…it makes total sense. I won’t know about “occlusions” or anything like that by just looking at his pod, but the ketone strips would definitely come into play if he’s had prolonged high BG’s that I’ve corrected, and they haven’t come down yet. (last paragraph of my scenerio post.)
Also keep in mind that in this example, let’s say his site was bad – he didn’t start generating the ketones at 250 mg/DL. He probably started generating them even earlier, as his BG started to climb once he officially had zero IOB. So he could have been ketotic for even longer than 3 hours.
Does that make sense?
So basically check everything I can check “hardware” wise, administer a sufficient amount of insulin, make sure he drinks a log, wait, rinse and repeat and if the rinse/repeat doesn’t work, consider changing sites since occlusion might be occurring or some other site related issue.
But again, I can do all of this w/o ketone strips. No?
Ketone strips (in my mind) are definitely something I do use, and will continue utilizing, when he’s high and hasn’t come down even after repeated corrections. Strips in conjunction with site changes, MDI shots, whatever it takes to verify the insulin is making it into his body.
Again, once I’m awake, though…I’m awake. I’m the type of person that jumps out of bed in the morning ready to start my day…waking up from the dead of sleep and staying awake for the rest of the night, if required, to make sure Liam stays alive, is par for the course for me.
Also, and sorry to be rehashing this, but another reason to check ketones anytime they’re sick is that sometimes the symptoms of the illness mask the fact that they are spiraling into DKA. So you can think to yourself “oh they’re just feeling crummy from the disease” but actually it’s DKA. And that’s something you can’t handle at home. You really want to catch those situations ASAP. Once they’re vomiting you’re already in the scary territory IMO.
Aye, I know DKA is life-threatening and I hope it’s something we never have to experience…I’ve heard stories and they scare the ■■■■ of me. Which is why I would never go back to sleep after correcting a “chronic high” I call them.
Yeah, i mean most of the time your protocol is fine. I think the point of ketone checking is sort of like the point of all those checks anesthesiologists, rock climbers or pilots have to do all the time to catch those random fluky situations. Like maybe your belay device is properly set but maybe not – the check is just a way to catch the off-chance when you forget.
In other words, 99.9% of the time, if you’re out of the habit of checking ketones, you’ll be fine and saving money and avoiding an unnecessary test. But by making more frequent checks part of the routine, you increase the chances of catching that 0.1%.
It’s also about time. You can think of it this way 0-3 hours no insulin = not a big deal. 3-8 hours – longer night ahead but kiddo will *probably be fine unless there’s some other mitigating issue like illness. 8-10 hours – DKA can set in. So these checks are basically meant to cut down the total time before you nip DKA in the bud. It’s always better to catch it closer to 3 hours than 8 hours.
The other thing is that I really do think it’s interesting and worth knowing to get a better handle on when a kid IS and isn’t likely to be generating ketones, which I suspect is different for all of us. We would never have known that , for instance, Samson could generate ketones when low or normal BG, and that for him, the number one risk factor is being disconnected from his pump for any length of time. Or NOT eating carbs. We only knew that because we were more aggressive about ketone testing than would ordinarily be expected.
As a result, in other situations when we don’t check (like he’s swimming and off his pump), we will give him a really big insulin bolus + some carbs and water when he reconnects, even if he’s been running low during the entire course of the swim. Because I guarantee his ketones will be at least moderate after those 3 hours. And if he, say, ate a low carb breakfast, then says he’s not hungry for lunch, I have in the back of my mind that he can’t really get by with less than say 30 or 40 g of carbs by mid-day, and will try to coax him to have snacks, even if his BGs look perfect. Because I know he tends to generate ketones with even moderate carb deficit.
Luckily for us I’ve never overslept long enough that the DKA could be an issue. The scenario I listed was fictional and the longest I’ve ever had a high (and the high wasn’t even over 250), was around 2 hours during the night. The BG was 238 when I checked it and even in that case, I stayed up until the correction worked and he was once again level in an acceptable range.