I recently received a text message from a type 1 patient who has been wearing a pump over 10 years.
“I need your guidance. My blood sugars have been in the high 200s and 300s since Thursday. I woke up with a 398 blood sugar. I’ve been eating out a lot and drinking too much. I think I need to follow a very strict low carb diet and less alcohol.” I called the patient and let her know I was sorry to hear she was feeling overwhelmed. I asked if her pump was working, “When you correct, does your blood sugar come down?” She said, “Yes.” “Did you check your ketones?” She didn’t know what I was talking about.
I explained and asked her to go to the pharmacy and get strips. I called the pharmacy. Sure enough there had been a prescription sent in before by her endo, but she never picked them up. She checked. She had small ketones. This was after she corrected, and drank a lot of water as I recommended she do. Her glucose levels were then in the low 200 range. Sure, better than 398, but taking no chances, I recommended she change her site, tubing, insulin, etc…, and check in an hour. She wears a CGM, so she let me know it showed she was coming down. Her “keytones,” as she called them, were small. I encouraged her to keep drinking water, keep a close watch on her glucose and ketones, correct and cover as she’s been taught.
She then told me she was going out to eat and didn’t know what to eat. We looked up the menu for the restaurant. She agreed to eat salad, bronzini fish, and broccoli for dinner. She had a plan.
Since she lives alone, I recommended she set her alarm and check her glucose, including her ketones, hourly during the night. She contacted me in the morning, with her glucose reading of 142mg/dl. “Keytones” were still small. Today, her plan is to watch her glucose closely, correct and cover as needed, check ketones 4 times a day, eat low carb, and drink a lot of water. We’ll be in touch.
- High glucose levels can cause type 1 diabetics to go into diabetic ketoacidosis (DKA), for the most part due to not getting enough insulin. Checking for ketones is recommended when levels are 240 or above. People who have type 1 and wear pumps are very prone to DKA, because if for several reasons including a pump breakdown the person is not getting the insulin they need to get, they have no “back up” insulin, so they can go into ketoacidosis.
- Don’t take anything for granted. Just because people have been taught, doesn’t mean he or she understands and can put in practice what they have learned, especially when things are not going well.
- Just because people have had diabetes a long time doesn’t mean they always “get it.”
- Just because people have worn a pump for a long time doesn’t mean they remember everything they were taught.
- Sometimes the longer people have diabetes, the more lax they become in their care. Managing diabetes 24/7 can be a lot work.
- Be a non-judgmental health care provider so patients can feel comfortable reaching out for help.
Note: After we ran this “Disaster Averted,” we received a lot of negative feedback relating to the original title (“Ketones May Be Culprit Behind Constant High”) which some of our readers felt was misleading. We removed this article to rewrite and were assured by several endocrinologists that, although the title was misleading, the basic article was fine. So we are putting this article back on our website with a new title and some added information. Please always feel free to contact us, however, if you disagree with anything on our site. We always appreciate the feedback as we strive to serve our readers as well as possible.
Joy Pape, MSN, FNP-C, CDE WOCN CFCN, FAADE
Associate Medical Editor, Diabetes In Control
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