I woke up this morning feeling unwell. My brain was cloudy and I felt slightly nauseated. Then I remembered briefly waking up a few hours earlier and seeing my CGM displaying the lost data ??? symbols. My overnight blood sugar traces recently have been particularly well-behaved, so seeing the ??? lost data indicator made me think that I’d change out the sensor when I finally arose for the day. At 4:15 a.m., I was more interested in returning to my sleep.
After I got up just before 7:00 a.m., I did a fingerstick and it surprised me with a 262 mg/dL (14.6 mmol/L). I can’t remember the last time I’ve been above 200 (11.1). It was at that point that the slight queasiness in my stomach took on a menacing meaning. I knew that feeling nauseous combined with a high BG comprise classic symptoms of diabetic ketoacidosis or DKA.
Familiarity breeds contempt
I’ve now lived with T1D for 36 years and I’ve never been through DKA. My diagnosis occurred as a slow-onset form of T1D now referred to as LADA. So I think my pancreas at the time of my diagnosis was still secreting enough insulin to keep my out of DKA.
A year ago, I read an account written by Wil Dubois over at DiabetesMine. In that column, he wrote how he was surprised with a DKA diagnosis in the ER, even though he is particularly well-informed about diabetes. He has written books on the topic and also worked for several years in a clinic that served many people with diabetes.
Wil’s writing on DKA caught my attention. This passage stuck in my memory.
What happened? I still don’t know. A lot of it is a blur. Something made me sick. I did throw up, but my sugar was at a normal level when it happened. But then things went south. My blood sugar level started rising and wouldn’t stop. I threw insulin at it, but it all happened so fast. So frickin’ fast. It only took a few hours, coasting just below 300 mg/dL, to send me into a full-blown metabolic crisis that left me in the hospital for three days, two of them in the ICU.
I had always thought that if well-informed and vigilant about the classic symptoms that I could simply take corrective insulin and head off all the bad consequences. I trusted the facts that Wil reported in his story and gained a new appreciation of the devious adversary that is DKA.
Back to my story
Following the fingerstick 262 (14.6), I used my Precision Xtra blood ketone meter, thankful that I had ordered a fresh complement of test strips from Amazon just a few months back. The ketone reading registered at 4.7 mmol/L, well above my usual 0.5-1.5 mmol/L caused by the nutritional ketosis I normally experience, especially in the morning.
I understand that anything above 5.0 mmol/L is edging into dangerous territory. In fact, if you read Wil’s account, he notes that he’s resolved to go to the emergency room if he has symptoms, like throwing up, and a reading above 1.5 mmol/L.
I immediately inhaled a 4 unit dose of Afrezza and delivered via syringe a 4-unit intramuscular or IM dose of Fiasp. My blood sugar was slow to come down but my sick-to-my-stomach symptom disappeared within an hour. I also set a pump temporary basal rate of 5 units/hour and ran that for about 90 minutes closely watching my BG levels. I changed the infusion site at 8:00 a.m. – should have done that immediately.
In fact it took two hours for my BG to fall to 209 (11.6). Ninety minutes after getting out of bed, I took another 4-unit Afrezza and a 4-unit Fiasp IM dose. I added a 4-unit dose of Afrezza at 11:05 a.m. with my blood sugar resisting correction at 158 mg/dL. Six and one half hours later, my BG is cruising sideways at 91 (5). I checked the ketone levels about every hour and they’ve trended down from 4.7 to 4.0 to 2.3 to 1.7, with the last one at 2.0. I will keep an eye on this.
Root cause unknown
I haven’t figured out the root cause of this incident. I inserted a new infusion site even though the existing one was only 24 hours old and had performed well the previous day. I half-way expected to see a bent cannula when I removed it but it was unimpaired.
Before bed the previous evening, I installed a new insulin cartridge in my pump. I do this on a separate schedule from site changes. It’s possible that I missed an air bubble in the cartridge and that accounted for the missing insulin. Since my Dexcom CGM was not displaying any glucose data after midnight, my Loop program simply reverted to the basal rates programmed into the Med-T pump.
What lessons can I draw from this experience?
I need to respond to sustained missing CGM data, even if it occurs during the night.
Intramuscular injections are a great way to begin treatment since you absolutely know that you’ve delivered the insulin.
Afrezza inhaled insulin also worked for me in this situation.
Since I live alone, I need to discuss DKA with my adult daughter who lives nearby.
DKA symptoms do not always appear. In fact you can still be in DKA without frequent urination, throwing up, or rapid shallow breathing.
Having a blood ketone meter with fresh strips and a working battery I count as a success. I will definitely keep these essential safety supplies on hand going forward. This has not always been the case in the past.
When DKA happens so infrequently, it’s possible to get surprised when it appears. DKA can be lethal and we should not turn our back on this real possibility for each of us. I hope that this story, like Wil Dubois’, reminds others that they need to pay attention and be ready when DKA shows up.
I feel fortunate as I was likely only an hour or two away from serious medical consequences. Diabetes never sleeps!