Ketone readings are important in Insulin Pump Therapy
A lot of times we see a new gadget or device and will give it a try. We often cast it aside after a few uses and go back to our old ways. We do this either because we can’t make the new device work or because we just don’t see the benefit.
I was part of a group that tried out the Precision Xtra meter. I tried 6 strips and I could not get a Ketone reading, so I just tossed it aside and went back to using a regular meter on my test patient.
One of our readers recently sent me this article and I wanted to share it with you.
Practical Application of Ketone Readings in Insulin Pump Therapy
Jill Milliken RN CDE
The risk of accelerated Diabetic Ketoacidosis (DKA) in insulin pump therapy is well documented.,
DKA is considered a preventable and manageable risk with proper health teaching during the pre-pump initiation phase. People with type 1 diabetes are familiar with urine ketone testing as part of proper hyperglycemia protocol, however; urinary ketone testing may be limited in many people with diabetes due to the following:
Ø Inability to produce urine on demand
Ø Strips may have expired
Ø Urinating on the ketone strip is considered undesirable by many children and teenagers.
Ø Do not routinely carry ketone strips in regular diabetes kit.
Insulin pump therapy and the Precision Xtra Ketone meter: a partnership of technology
People who have chosen to use insulin pumps to treat their type 1 diabetes relate the learning experience to a “back to square one” approach similar to that of when they were first diagnosed. This is often a period of renewed interest in diabetes self management behaviors such as blood glucose monitoring, carbohydrate counting and interpretation of blood glucose. Revisiting the subject of ketone testing during this pre-initiation phase leads to a further increase in knowledge in this domain. It is for these reasons and the desire to minimize the risk of DKA, that the Precision Xtra Ketone meter has been incorporated into a pre-pump training and orientation package developed and distributed to each person initiated on an insulin pump in the community.
The following case studies represent practical applications of the Precision Xtra meter during actual situations.
Case 1
“Joe” is a 14 yr old boy living in a small rural community in Ontario. Joe had been initiated on an insulin pump for a very short time when the incident occurred. He called on the morning of the 5th day into pumping with a blood glucose reading of “Hi”. He repeated the test with the same reading. He was then asked to perform a blood ketone test which yielded a result of 2.7mmol/L.
This information confirmed the decision to give insulin by injection and troubleshoot the pump system. It was then discovered that during his third “site change” Joe had placed the syringe reservoir (containing insulin) incorrectly in the back of the pump. This problem had interrupted the delivery of his insulin overnight.
Discussion:
Even the best of preparation and training cannot completely ensure that all unforeseen events have been discussed or the message retained by the client.
Ø A protocol for troubleshooting, emergency contact numbers and 24 / 7 coverage was provided.
Ø Telephone management during an acute situation is difficult if the client is feeling symptomatic.
Ø Blood glucose levels provide the pump educator with information to make accurate and correct judgements. This is especially important when distance or other barriers exist as in this case.
Ø Without confirmation of the accuracy of the blood glucose reading, advising to give Humalog by injection over the phone is a risk.
Ø With a blood ketone level reading, the situation is confirmed at the earliest possible stage and can be managed properly.
In this case, Joe was managed in his own home. Interventions included: insulin by injection and infusion site change, a temporary basal rate increase, oral fluids with Gastrolyte, and q2h blood glucose and blood ketone testing. Joe’s blood sugar was back in target range by afternoon. His technique for preparing the pump for infusion was reviewed with the family. The rationale for suggesting site changes in the morning was also reviewed. The use of the Precision Xtra was instrumental in the swift management of this situation and prevented a costly emergency room visit.
Case #2
The mother of “Bob”, an 8 yr old boy called with her son’s blood sugar reading of 24mmol. The boy was experiencing vomiting and was refusing to cooperate with his parents. They were instructed to test for blood ketones and troubleshoot the pump system. The result was 1.7mmol/L using the Precision Xtra Meter. When the infusion set was changed, it was discovered that the cannula or small tube that is inserted into the
subcutaneous tissue had become dislodged and was lying on top of the skin but hidden by the dressing.
Discussion
Discovering a high blood glucose level is often a crisis for a family of a child. Many times, the steps in the hyperglycemia protocol are not revisited or remembered during this time. As with Case #1, blood glucose and ketone testing took place q2h. In this case, 4 hours later the ketone level was 0.8mmol showing that the interventions of oral rehydration, an anti-nausea medication and insulin replacement using an injection followed by a
higher temporary basal was appropriate. In 6 hours, the child was ketone negative in blood sugar target range and outside playing.
In Conclusion
The role of the pump educator is to gather the necessary information and provide clear concise direction to the client and family. Insulin pump therapy is not without risks. Novice pump users may have heard the messages provided by their pump team prior to initiation, but until a problem arises they may not have a healthy respect for the rapid deterioration which can be experienced with the interruption of their insulin infusion. The discussion of “what went wrong?” should take place at a later time when the crisis is over.
Having all of the “tools” at their disposal makes the pumper and their educator a more prepared team. The Precision Xtra Meter is an essential tool in the management of type 1 diabetes and it is especially important for those considering or currently using insulin pump therapy.
About Jill Milliken RN CDE
Jill has been an insulin pump trainer since 1998. She currently resides in the Quinte Region. Jill is the two time 1999 Bayer Award winner for “Diabetes Education Innovation” and “Applied Diabetes Education Research”. Also in 1999, Jill was acknowledged by the Ontario Council of Regents for “Excellence in Community Achievement” with a prestigious nomination for the Premier’s Award. Jill presented a symposium titled “Internet based Diabetes Education” at the CDA Diabetes Educator Section Conference in Halifax in Oct 2000.
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