Flaws in technology: a case of dka

WRITTEN BY:Ilse Michelle Mora Rodríguez

Frightening territory

When I was diagnosed, I was in diabetic ketoacidosis (DKA). After that, it only happened to me once. This was in February. There were flaws in the technology that I use and I spent a few hours without insulin, which triggered this DKA event. The day before, I had a blood glucose level of more than 400 when I woke up. To date, I do not know the causes but it was a very high number that, thankfully, I was able to correct. I changed my cannula and made sure that the insulin passed properly.

The next morning I woke up very thirsty. I must confess that I did not measure my BG levels because I had patients booked in appointments very early. I did not have breakfast or anything. I later measured my glucose and surprise! The result was more than 450 mg/dl. I know the treatment plan so I started drinking water. Within two hours, my glucose had dropped a little but not too much. I had abdominal pain. My glucose remained at 400 mg/dl all morning but I could not leave my work area since I was alone with many patients.

At around two in the afternoon, I felt awful but I managed to leave work. I already had double vision, nausea, vomiting and abdominal pain with a BG above 450. I felt so bad that I went as fast as I could go to the emergency room. I knew I would need help so I got in touch with my endocrinologist friends and internal medicine doctors who started doing tests, and I started to inject insulin without using my pump.

I spent much of the afternoon and night unable to determine the cause of this event. When I was entered the emergency room and I removed the cannula, I saw that it was broken. Failures in technology for the management of diabetes can cause incredible damage. We must remember that these are machines and as such, they will fail from time to time.

The takeaway

From this experience I came away with four main points that I want to share with you:

  1. If your glucose is high and you use an insulin pump, the best suggestion is to correct once with the device. If your glucose does not drop within a reasonable period of time previously discussed with your health care team (two hours for some is sufficient) proceed with a manual correction (injection).
  2. Change your infusion set. If your BGs did not drop after the first correction, don’t wait, change your infusion set to rule out that cause! Very often there may be obstructions, bent cannulas and other problems in the equipment that can prevent insulin from reaching your body and this can lead to DKA fast.
  3. Check your insulin. Check that the insulin you use is in good condition, that is, that it has been stored at the correct temperature and that it has not passed its expiration date.
  4. Do not forget a backup plan. ALWAYS take spare supplies with you. Make a kit so you can carry syringes, strips, extra insulin and if you use an insulin pump, include reservoirs and infusion sets. This way you can rule out a failure in technology or change these if necessary.

DKA will not always occur when we have many days of illness or when we have many days with high glucose levels. It can present itself at any time as a result of failures that do not depend on our own management. We should always be ready to handle DKA urgently and keep ourselves out of danger.

2 Likes

I’ve been wanting a pump for the last year, but this type of scenario has been one of the main things that turns me off still getting one. You’ve got some good tips there on how to deal with this though.

@Donman90

I think a good part of the problem mentioned above is being at work and not being able to correct for it right away. I always have a back kit with me, I’ve knocked a pod off, had a test and had to remove it etc, so a back up kit is needed.

I am one of those that goes to 300’s within 2-4 hours of not having insulin, it takes a little bit of time to figure out my pod isn’t working, then a little bit more to bring down BG’s. And usually I am taking a shot when I’ve had a failure to make sure I get the next dose no matter what.

But I used to get 300’s all the time when I was on shots, the insulin wearing off before 24 hours, not being able to correct or even know about my DP. forgetting my basal shot before I left for work and relying on bolus shots all day to correct BG’s or? etc.

So in other words, you just trade 1 set of issues for another. A pump isn’t for everyone, that’s up to you, but I love mine, it makes it so much easier to correct for smaller BG numbers and snacks etc. But I just wanted to point out it’s really not so bad just different!

3 Likes

@Donman90,

I’ve been using a pump for the past 12 years, and for much of that time have struggled with infusion set failures due to allergic type reactions to them. Like @Marie20, I develop very high blood sugar and high ketones within a few hours of no insulin, and have been near DKA several times due to site failures.

I do three things to protect myself from this:

  1. I change my infusion sets frequently, and will change them out at the first sign of irritation (itching or soreness). If I’m running high, I’m quick to suspect the infusion set and change it out. I’m also not shy about giving a correction with an injection if I have any doubts.
  2. I use steel sets because I react far less to these than plastic sets. The advantage to using metal sets for everyone is that they cannot bend and cut off insulin flow. I’ve still had even metal sets go bad, but only due to site inflammation issues, not bent cannula.
  3. I use the “untethered regimen” and take a small dose of basal insulin every day. I provided about 15-25% of my total daily basal with basal insulin and make up the other 75-85% with my pump’s basal rates, so I still have the flexibility of adjusting the pump’s basal rate, but it ensures that I have at least some insulin in my body at all times.

Since implementing these strategies, my instances of high blood sugar and ketones has virtually disappeared. Of course, part of pumping is the necessity to monitor closely…you can’t ignore a problem for hours and not expect to run into major trouble. I do always carry an insulin pen, spare infusion set, and ketone meter with me, just in case.

7 Likes

I like your post Jen. I particularly like #3. My DD just started pumping and dka is a real fear of mine as she heads off to uni this fall. She used to use tresiba and it worked well. Her basal is about 36u per day. Even if she had 9u of tresiba - do you think that would do the trick?

In regards to actually preventing DKA, I’m not sure. Might be a good question for a doctor. I can still suspend my pump for half an hour and create a 1-2 mmol/L rise in blood sugar, so I’m doubtful that if I went hours receiving no insulin that the 10u of Tresiba I take would do anything to prevent DKA. But it does help (I feel) to keep my blood sugar steadier. I choose to do a a minimal amount of basal insulin, though, because I still really want the flexibility of the pump. The first article on the untethered method that I came across about 15 years ago recommended taking 75% as a basal insulin and making up the other 25% with a pump. That would allow one to detach for significant amounts of time without issues. But it would also take away a lot of the flexibility the pump offers.

1 Like

I think she should have gone to the er right and closed her office etc. You don’t want to wait for things to get worse.

I always do an inj right away if I think I am going to dka territory and now I change the inset and insulin as well.

On a pump this can happen even without a broken cannula etc. it can happen just from dehydration, illness and heat, over exertion etc.

2 Likes

This is true of MDI as well though, no? Anyone with diabetes has to be careful about dehydration, illness, over-exertion, some medications, and so on?

1 Like

In my opinion, the risk of a bad site causing absorption problems is that the site may start working after you replace it.

So then you have a potentially large correction dose via the new site or syringe, and you have the insulin from the old site now suddenly absorbing and working. If any of your correction doses with that site were large, then there’s the potential for serious problems.

This happened to me once and the drop was so bad that I switched off the pump. I couldn’t think of a way to prevent it from occurring again. Catching it earlier might have helped, but there must have been significant pooling under the site that suddenly absorbed all at once, so catching it earlier would’ve only helped to a degree. It was a life threatening low, and probably the worst I’ve ever had in my life- at least while awake.

1 Like

This is also a big fear of mine. I tend to do smaller corrections over time instead of one big one and correct over a longer period of time. When you’re unsure of exactly what is causing the bad site/kink/occlusion you just can’t be sure of how much actually got delivered.

1 Like

Yes it is true, but it is much worse on a pump, in my experience anyway, with 3 near dka and one hospitalization all on the pump and none on mdi. I have never been even close or had ketones etc on mdi with long acting

Dont correct via a bad site, do an inj, change out the whole site and increase basal-and don’t stack any corrections.

You don’t know if a site is bad until you do a correction that doesn’t work.

Whether you do an injection or you dose with the new site doesn’t matter if the insulin from the “bad” site starts absorbing.

If you don’t correct with the new site, then that means you’re okay with running high for hours on end. Which I’m not.

Anyway, my management is way better now than when I was on a pump. My last A1c was 5.1%

Wow - you gotta be happy with that (5.1%) :tada: :boom: :tada:. Congratulations

1 Like

Thanks :slight_smile:

I really am. I owe it to a cgm, Afrezza, and Lantus. Lantus changed my life when it first came out, and Afrezza has now changed my life again.

I feel great. I’m in range almost all the time (only 1.6% above 180). I can dose when I eat without any planning needed. I can exercise easily because I won’t have leftover fast acting in my system.

I honestly never thought I’d be so lucky to have it this easy. I’m still working on pulling down my standard deviation a bit, but overall I’m incredibly happy with my numbers. I wish everyone could have access to Afrezza.

4 Likes

Kate - Those are fabulous TIR’s and SD’s for someone who eats carbs.

My doc threatened me when I turned a 4.6 A1C a couple of months ago, so for the next little while I’m struggling to increase my BG levels LOL

Even so, it’s usually under 30 or 40 grams of carbs/day, and my Clarity AGP is only marginally better than yours (99% TIR, SD 1.1 [20 mg/dl] past 30 days). Hopefully next months A1C will be 5 or higher so I can get doc off my back :stuck_out_tongue_closed_eyes:

I really am. I owe it to a cgm, Afrezza, and Lantus. Lantus changed my life when it first came out, and Afrezza has now changed my life again.

The one insulin we can’t get in Canada is Afrezza. It was submitted to Health Canada more than a year ago but is still not approved. Keeping fingers crossed that we’ll see it soon

2 Likes

It’s pretty impressive to me!

I’ve never dipped into the 4s before! It’d be cool to see that number one day, but I’m happy with where I am right now.

I’m crossing my fingers too! :crossed_fingers::crossed_fingers::crossed_fingers:

I hope the company stays afloat!!! It’s life changing stuff. I’d be deeply saddened if pwd didn’t get to benefit from it simply because of corporate sabotage.

I said correct with an injection not a new site. The reason being an injection nearly always works much faster for me and will not have absorption issues that a new site can have. Then you know that you have good insulin in you working right away, assuming the point is to get down a super high bg heading to dka which happens very rapidly for me.

For me I know when there is a rapid rise and other signs it is serious so after a few close calls and one hospitalization now I don’t wait to see if an inset is the issue for whatever reason because it is not worth it. I change the inset immediately and I change the whole cartridge and insulin out. And inject asap, immediately with no Iob and sometimes with it as well.

It just happened to me last night, the inset had popped out and I did not get a full bolus and was without basal, if I had waited any longer I would have ended up at the er and it was bad enough as it was.

That is great mdi Is working well for you. For me it was a disaster, and I was lucky to survive nearly 3 years.

My original comment was this:

To which your response was this:

No one can know whether a site is bad until they do a correction that doesn’t work.

If you correct with a syringe or with a new site is irrelevant. I totally agree that a correction with a syringe is better because the new site might be bad too, but even if you correct via syringe, you’re still stacking insulin because there’s the potential that the insulin from the “bad” site might start working.

That was all my point was about.

There’s no way to remove this risk. Since I didn’t want to experience that again, I went off the pump.

I’m sorry you had a bad site last night. I had a lot of problems with that on the pump. The numbers I just posted were not possible for me on a pump. My average was much higher and my standard deviation was higher as well. I had a lot of roller coasters and failed sites. My insulin absorption is much more predictable on mdi. Of course, Afrezza works totally differently and really helps me avoid the extreme lows and highs too.

Thanks😊
I do know as I said with certain signs so I act immediately to avoid er dka etc. I no longer wait to see “if” a site is bad or if insulin is bad. It is a tricky decision with iob and an easy one without.

I change everything out and inject immediately now without iob. I also did a 200% basal increase this time for a few hours and needed it. Last night I had unknown iob as well as no basal for a certain amount of time. So I waited a bit too long and due to everything accidentally inj with expired insulin. Which made the situation even worse. And my night is not over yet because I am not nocturnal :joy_cat:

I will never go back to mdi for any reason except an emergency, main reason being able to control my basal and treat lows. I feel so much safer. Mdi was very unstable basal for me and dropped me very low and up very high at times, just awful. Afrezza is not an option for me due to asthma and lung issues.