High BG and large keytones. How much insulin to take by injection?

This morning I was awaken early to find a surprisingly high (300s!) blood sugar... I tested ketones and they were also present in large amounts. (The long story is here).

When I started on the pump, the CDE who trained me told me to take six units of insulin by syringe, then to monitor my BG going forward and correct as necessary, just keeping in mind that those 6 units wouldn't show up as "on-board" by the pump. It seemed arbitrary and not based on any actual measurements, but it's easy to remember.

Since moving and switching doctors, I've been given different advice: to calculate the correction based on my BG at the time, then to do some other mathematical calculation (I forget what it is) to determine how much insulin to take. It made sense, but was far too confusing to remember, and too hard to calculate in my head, especially in the middle of the night with my head spinning.

Obviously, since I can't remember the second bit of advice, I took the first. But what is the RIGHT thing to do? Is there a right thing, since there's no way to really know how long the basal was knocked out for? Is the right thing (keeping a scientific calculator at my bedside) really practical?

I think I have seen on here that some have disconnected the pump but do a bolus to keep track of IOB. I

Ketones are almost always present in the morning simply from fasting. So, low ketones from fasting were combined with some from your BG to probably equal high ketones.

Quite arbitrary to tell someone to take 6 units. I don't pump, but I correct highs without calculating IOB or basal because IOB clearly isn't working to lower BG if it's been hours since my last injection. Only time I figure IOB is with a high close to a bolus. Of course, your basal is different from mine on MDI. My ISF consistently works as correction, even though it usually takes a while to see it come down.

My understanding is as follows:

Actual BG - Target BG/ISF (Insulin sensitivity factor) X 1.5 = insulin amount to bolus

My sheet (from my daughter's pediatric team) does note that if your BG is over 20.0mmol (360) then use this number as your actual BG in the calculation rather than the higher number. Once you are below 20.0 (360) then use the actual BG number in the calculation. Once ketones have cleared then use the usual correction formula: BG - target/ISF.

I usually took a couple of units and would hedge my bets by doing it in my leg and going for a walk to 1) activate it faster and 2) waste time I'd spend fretting about "why isn't it coming down?". I know that exercise is counterindicated w/ elevated BG and all of that however I figure if it gets the BG down faster, it helps? I can wait 4 hours without walking or an hour with walking seems like a clear benefit and worth whatever the risk might be.

Or the IV shots. Those work quite a bit faster and, of course, are horribly dangerous.

Some of your other messages have made me think about taking it intravenously, but I don't know that I could bring myself to do it. It's risky, and besides, the thin needle would probably snap off and get stuck in my vein. Not worth it.

At that time in the morning 5:30 am - dead tired - I was in NO MOOD to do any sort of exercise except climb back into bed. Oddly, when I woke up for good, ready to shower, my BG was 171 -- no correction -- and a half-hour after my shower I was down to 94, 78, or 91, depending on which of the three consecutive tests I did (not believing the first following the 171, nor the second following the 98). I still can't figure that one out.

Coupled with the double-test at 5:30am (to see if the 316 was really real -- the retest was a 281), I wasted five strips during this whole episode to test my blood sugar twice. It's why I hate when T1D's are allocated a strict number of test strips per day... but that's another topic for another day.

This was a BG of 315 after a few correction boluses, so it was definitely ketones due to no insulin -- no doubt in my mind about that one. The stick turns dark-purple immediately kind of ketones.

Yes, the 6 units is arbitrary, and I don't know of that advice was customized for me or if this CDE gives it to all her patients, but I just wanted to get out of ketosis quickly so I took it. And as I discussed on Tu awhile ago, I'd rather be low than high.

Just to see if I understand this correctly... so if my actual BG was 318, my overnight target is 115, and my overnight ISF is 75, I should be be doing the following: (I figure the subtraction of BG's should happen before dividing by ISF, and the units - mg/dl or mmol/l don't matter since they cancel out anyway)

(318-115) / 75 X 1.5 = 4.06

I suppose the 1.5 is based on the typical daily 2/3 bolus, 1/3 basal ratio (which is my ratio, btw..)

Essentially, I'm using the bolus wizard calculation and taking one and a half times it's recommended amount. 4 units....I suppose that seems about right, considering 6 eventually brought me low, but it did do it quickly, which was my goal!

I have heard from a number of sources the recommendation to increase your correction bolus by 25-50% when you have very high blood sugars. That is the source of the 1.5 factor.

I also like the idea of intramuscular correction injections. With an intramuscular injection the insulin action is rapid, helping to bring down your blood sugars quickly. Bernstein uses his delts, I just inject in my quads.

I know that higher highs are tough to bring down, so I thought that would be where the 25-50% additional comes in; but in this case, there's missing basal which also needed to be accounted for.

I tried to get a muscle (in the arm), but I missed. I haven't done much exercising lately, and on my body, a good muscle is hard to find.

What I know, for myself, from practical experience is that my ISF with a pump is much different tham my ISF with MDI. I'm not sure what's to be gained by injecting into muscle, but I'd have to inject twice as much as the calculations specifiy using MDI to bring my BG down from the 300s, so I just correct using my pump now.

I suck it up and hope for the best. In your circumstance, I would have been awake in an hour or so anyway so I'd do what I could to monitor the situation. At that point, whether it was back into normal range in one, two, or three hours would not have made much of a difference as long as it came back down.

Thanks for the video link to the intramuscular injection info. I learned that Dr. Bernstein uses a 5/8 inch long needle. The spare syringes that I have around are 5/8 inch long. I had thought that they were not suitable for IM injections.

Dr. Berstein also confirmed my belief that painful injections are associated with hitting a blood vessel. He also stated that one could stop the bleeding in that case by simply applying pressure to the site for one minute.

BSC - Do you use IM injections to bring down high BGs? Does your experience dependably coincide with Dr. B's assertion that IM insulin injections will bring down high BGs faster than a subcutaneous one? If Dr. Bernstein is correct then this practice should be used by every insulin using diabetic.

I also read that vigorously rubbing the injection site immediately after the injection will speed the insulin absorption.

Every time I watch the phlebotomist draw my blood, I wish that I could uneventfully execute that move to bring down high BGs super fast.

I wonder if we diabetics could be taught that skill?

FHS - It's been so long since I used MDI, I don't remember using a very different ISF number for MDI vs. the pump. I haven't used MDI since 1987. I don't doubt your experience.

The only thing that worries me about using the pump to deliver a correction for BGs > 300 is that the super high BG may be the symptom of a pump/site failure. At that point I need to initiate a positive counteraction with a high degree of confidence. Giving a correction that fails to do its work greatly increases the risk of DKA. That's a chance I'd prefer not to take.

Yeah, that's definitely a possibility worth considering and definitely a reason to bolus wit ha syringe.

Luckily, I've rarely been over 300 in the last 2 years. In fact, the only times I have been over 300 are situations where I had to bolus with a syringe instead of my pump to cover a meal. I just wayyyyyy underdosed because of the different ISFs.

Other times where I have been close have been a mix of underdosing and bad sites. Either way, I figure the best way to find out if it is my site is by bolusing with my pump. I'll burn strips hourly, or even every 30 minutes to monitor the situation.

That's exactly what the ketone test is there to determine. If ketones are present, then basal insulin wasn't getting into my system and the pump site is no good. I could change the site and then pump the correction, but I feel it would work faster by syringe if I could find the muscle. And even if I can't, it takes time to prep a new site (fill reservoir without bubbles, insert infusion set, etc), and I wanted to remedy the situation as soon as possible.

If ketones were not present, or I could explain the high BG with poor eating or a missed bolus or something, then I'd go ahead and correct with the pump.

Sounds like everything worked out for you so it lookes like you did the right thing.

That's a point that I had not considered before. If ketones are present then the site is bad and it's most likely bad because of the interruption/reduction of basal insulin. DKA does need some time to develop and a high blood sugar excursion after a meal does not trigger ketones if normal glucose is restored in a few hours.

I need to get some replacement blood ketone strips for the meter I got last year.

A bit off-topic, but do you use the Novamax blood ketone strips? I just use the urine ones -- and they're way over a year old. But I basically use it for a "yes" or "no", the value isn't all that important. (Unlike the transition from urine glucose to blood glucose tests, which was VERY important!).

Do you find them to be better?

You presumably already missed the basal, but the correction would restore a normal blood sugar. If you put in a new site and restarted the pump, it would be an hour or so before your pump basal would have an effect. But by that time, you probably have already dealt with at least one cycle of correct and test.