By Dr Morrison
An excellent training course for dealing with high and low blood sugars can be found online at the online pump school at the medtronic minimed site. Even though you may not even intend to use an insulin pump the course goes through a realistic and methodical training that is just as relevant for injectors.
Your immediate family and important carers should do it too. After all, what happens when you are too ill to help yourself? You may need to have a calculator handy. The blood sugar levels are given using the US system and if you are used to UK figures, as indeed also happens in Canada and Australia, you will need to divide the US figures by 18.
Vomiting, Dehydrating Illness and Infection—When do I ask for professional help?
When you get vomiting on more than one episode, nausea to the extent you cannot eat, fever of more than 24 hours duration, severe diarrhoea or any form of infection you need to contact the triage nurse, diabetes nurse or your doctor for advice.
With diabetes it is much safer and easier to prevent the potentially dehydrating illnesses from getting worse than it is to fix you if you are in a severe state. Please don’t put off that phone call.
How does diabetic ketoacidosis develop?
Any infection will raise your blood sugars. This in turn leads to increased urine output and higher blood sugars. The higher the blood sugar the more insulin resistant you become. Higher insulin levels will then be needed to get things under control.
If your peripheral circulation shuts down your cells will start to metabolise fat and make ketones. Ketones take water from the body on the way out of your kidneys and you will get more dehydrated.
High levels of ketones also make you vomit.
Symptoms of DKA are:
- nausea and vomiting
- rapid deep breathing
- loss of appetite
- abdominal pain
- visual disturbances
It is a truly awful vicious circle. The thing to do is to prevent it happening in the first place.
What do I do if I am not getting better ?
If you become unwell at any time it is important to keep your fluid intake up, continue your usual medication or insulin, check your blood sugar levels more frequently than usual eg every 2.5 hours.
Check your urine for ketones if your blood sugar level is above 13/230. In fact even if your sugars are normal and you feel queasy, check for ketones. Remember that ketone testing stix are unreliable six months after the container is opened regardless of whether they appear to be in date.
Get prompt medical advice if your symptoms don’t settle or your blood sugars are too high. Information you can give about your current blood sugar, the trend in blood sugars, ketones or not, your insulin doses and your correction doses and how well you are keeping down fluids and passing urine are necessary for the doctor or nurse to make an accurate assessment.
If you attend A and E bring your Emergency Cards especially if you do not speak the language they are likely to speak in the hospital fluently. Bring all your kit and a reliable bi or multi-lingual helper.
Do not sit politely at the back of the waiting room if you are a vomiting insulin dependent diabetic. They must assess you RIGHT NOW. They may have to drip you RIGHT NOW to SAVE YOUR LIFE.
If you are incapacitated or having surgery a friend, parent or sibling who knows how to manage your diabetes must be with you at all times to test and treat you as needed.
They may have to insist on saline drips until your blood sugars are in your normal range. Current hospital practice is to switch to dextrose ie sugar drips when you go below 10 / 180.
They may need to bring you in diet drinks or special food when you are in the recovery phase.
How to Manage Blood Sugars When I Actually Feel Okay?
Well, I hope you understand. I just had to get the blood and thunder stuff out of the way first (!). If you think your blood sugars could be running high check your blood sugars. Tiredness is probably number one symptom of high blood sugars. If you are high you can do some things to bring it down.
- 15-30 minutes of gentle walking or other exercise can bring it down.
- Drink plenty of water if you are high.
- If you are high three days in a row at the same time you need to consider an adjustment to your insulin dose.
- Watch out for high blood sugars due to old or contaminated insulin. If in doubt throw it out!
- Then watch for lower blood sugars when you start a fresh vial.
- If you have been high due to an illness, stress or surgery and have gradually upped your insulin to deal with it, be prepared for low blood sugars when you recover.
- Girls and women often go high just before their period starts.
- Remember your flu jag each autumn. It could spare a lot of grief.
- High sugars and widely swinging blood sugars both cause complications that among other things age your blood vessels. So does smoking. You don’t need smoking on top of all this diabetes stuff. Do you?
- Correction boluses can be given for high blood sugars.
- One rule of thumb is that one unit of a rapid acting analogue will deal with about 2.5/45 units of blood sugar. But this is an adult average and you are not average. You are you.
The more you weigh and the higher your total daily insulin dosage, the less your blood sugar level will drop for a given measure of insulin. For many people a given unit of insulin will drop you much more if it is given at night compared with during the day.
Your correction dose will also depend on your individual insulin sensitivity for the time of day just the same as for your meals. You’ve worked this out for your meal coverage haven’t you?
Dr Gary Schiener has charts you can use to estimate your correction doses in his great little book “Think Like a Pancreas.” Again this is simply a guide. It is safest to start at correction doses a little lower than he recommends and take it from there. Guess and test. Again and again.
Hang on a minute. I’ve not done yet. You cannot go off and correct high blood sugars with insulin willy- nilly. You also need to consider how much previously injected insulin is still active or you could drop too low. Gary has charts for this too. Gary has loads of charts!
If you do go ahead with a correction bolus please check your blood sugar after an hour to make sure it is on the way down and that you are not going too low.
Dr Bernstein thinks that the residual insulin on board calculations just makes the whole correction dose thing just too complicated. I agree with him.
Dr Bernstein recommends that you only correct with insulin at your pre-meal and pre-bed times. This is so that you can assume that no residual effect from the insulin other than your basal is present. This is not quite true of course. Remember the tail effects of regular and rapid acting insulins?
You also need to consider if your sugars are high due to a meal that took longer to digest than usual. Pizza for instance is notorious in this respect. It takes 8 hours to digest and a minimum of two spaced doses of regular insulin or three spaced injections of rapid acting analogue insulin to cover it completely. You need a five hour space between strict low carb meals before food will be having no effect on your blood sugars at the next meal.
For any teenagers out there who are now desperate to get on with managing their own sugars some final words of wisdom from Spike and Bo.
“Let your parents take as much care of you as they want and help you out as long as they can. Someday you will be on your own and they won’t be there to remind you to take your kit and make you a healthy high protein breakfast.”
1. Three of these tend to raise your blood sugars:
a Menstrual hormones.
b Hypoglycaemia rebounds.
c Weight gain.
2. If you have a blood sugar that is unexpectedly high you could have…
a An infection brewing somewhere.
b Been drinking too much diet coke.
c Given yourself too much insulin at the last injection.
d Eaten too little carbohydrate with your last meal.
3. If you are insulin dependent and your blood sugar is 13/235 or over the next thing you should do is:
a Call your doctor.
b Check for ketones.
c Exercise vigorously to bring your sugars down.
d Have your usual amount of insulin and food.
4. You decide to give yourself a correction bolus to bring down a high blood sugar. After giving the injection there is one of these things you really should NOT do:
a Check your blood sugar 30-60 minutes later.
b Drink a large glass of water.
c Go for a gentle walk.
d Go to sleep.
5. Before you give a correction bolus you need to consider three of these:
a Whether any previously injected insulin is active and for how long.
b Your insulin senstitivity for that time of day.
c Recent previous exercise.
d Your current weight.
6. If you are insulin dependent and ill and vomit more than once you should do one of these things:
a Go to bed till you feel better.
b Check your blood sugar and call the doctor or nurse for advice.
c Have some lucozade to aid recovery.
d Stop taking food and fluids so as to give your stomach a rest.
7. You are vomiting repeatedly. Your sugars are high and you have ketones. What single course of action is best:
a Go to bed.
b Call NHS 24 from some advice from a nurse.
c Phone a friend.
d Go straight to A and E with your overnight bag and diabetes kit.
Have you got it?
1. ABC do. Alcohol tends to give low blood sugars due to its effect on the liver of suppressing gluconeogenesis. Menstrual hormones give a cyclical monthy pattern. Weight gain has a very gradual effect. Whether hypoglycaemia rebounds are due to overtreated lows or adrenaline and cortisol rushing in to save the day is a controversial phenomenon. You may have to find out for yourself.
2. A is correct. Dental and gum disease can be a hidden cause. Any flu like illness can play havoc with your blood sugars.
3. B is correct. Remember that ketostix lose effect even while in date if the container has been opened more than six months before. Exercising when you have ketones and are relatively insulin deficient can push you into very high blood sugars and ketoacidosis.
4. D. You must NEVER give a correction bolus and go to sleep. You may overcorrect and have a severe hypo. Rechecking is mandatory and the water and walk may help.
5. ABC are correct.
6. B is correct. Although the other things listed are often done by non diabetics these activities no longer apply to you. Don’t do what your mum did with you were six. Do what you need to do NOW. And don’t delay making that call.
7. D is best. You need a DRIP and you need it NOW. Phoning a friend is absolutely fine. They can help you get your kit, drive you to hospital, collect your kids from school and look after any pets. No going to bed while they make you a pot of chicken soup though!
- Acknowledgments to: Dr Richard Bernstein , Dr Gary Schiener , Spike and Bo Loy and Medtronic Minimed .
- Medtronic Minimed’s pump school gave me the idea to expand the material into the course you have completed right now!
Dr Bernstein’s Diabetes Solution has a particularly important chapter on the subject of dealing with vomiting, dehydrating illness and blood sugars. If your carers read nothing else they must read this. Diabetic ketoacidosis is a frightening run-away-train sort of illness. There is significant mortality rate even if DKA is treated in the best of hospitals.
Prevention is therefore paramount. Dr Bernstein’s recommendations may vary a bit from those of your diabetic clinic. In particular he emphasises aggressive and early management of any condition that has the potential to develop into DKA, hydration with a non sugar electolyte mixture which you can easily make to his instructions and close liaison with an experienced and knowledgeable health professional early in the symptomatic phase.
There is no point in reading all about it when you are throwing up rings around yourself. You must have the supplies he recommends and know what you are going to do AHEAD of events.
Having metoclopramide injection (UK) at home with the appropriate syringes and needles came in really handy when my son was in this situation. You would benefit from having this drug or similar one in your emergency kit. It can be necessary after vomiting from glucagon administration as well as to terminate a vomiting attack from a viral infection or high sugars. It is not to be used instead of medical advice but as well as. After you have vomited twice you must contact your doctor. If they think that an injection is required at this stage a carer can give it or have the diabetic person can do it. This can save valuable time on a house call or trip to the clinic or A and E department.