ellie, relax, depth breaths, i know this is hard, it's a huge adjustment but you're doing it and staying with it. good job, girl! use your CGM as your guide, you've got a great pump nurse/cde, right...type 1 whom you trust, no?? look what you've accomplished lately; a CGM and a pump when you said you could't or wouldn't. so proud of you! :) if you're coming down you're getting insulin. and it's great you had a good basal, flat..OMG, that's fantastic. how much basal did they start you with, what's your basal rate? if you're flucutatng a lot and also stressed, you'll feel icky. i'm sure they walked you through what to do if you stay too high and don't come down with pump corrections, change site, give injecting bolus correctioin, etc...deep breaths, girl! :)
I would highly recommend getting strips for your ketone meter. It's much, much more accurate than urine strips (kind of like comparing testing urine sugar to testing blood sugar). This morning I randomly woke up at 313 but ketones were 0.0 mmol/L - and it came down MUCH faster than it would have if I'd had ketones (I also knew that it wasn't from a pump issue - maybe a rebound high or late-digesting food, I'd corrected a 342 before bed so obviously that hadn't dropped, so who knows).
Interesting. I had ketones almost constatnly when I was eating 50g a day. Maybe it's partly because I still had highs and lows, even on such a low-carb diet.
So my question would be, does eating low-carb further increase the risk of DKA for those of us on pumps (who are producing no insulin)? I'm thinking of my experience where I was eating low-carb, had low levels of ketones (small or medium) constantly, and then had an infusion set that kinked. Within three hours the ketone strip turned darker than the darkest available colour and at the time my blood sugar was over 300. I have never had ketones that high before, even with a kinked set and blood sugar of 300, while not eating low-carb. Normally it might result in medium to large ketones - not ketones off the scale.
I'm pretty sure 250 is the cut-off to start worrying about ketones.
Isn't the increased-risk-of-DKA thing included in all pump training? I clearly remember it being included in mine - I got the training when I had sort of forgotten about ketones and all that from when I was a kid, and it sort of freaked me out at the time.
I had a similar problem with ketones when I started on the pump. For me it was that my basal dose was too low, so I wasn't getting enough insulin to meet my basic needs if I hadn't eaten and thus taken a bolus for the meal.
I fixed it by eating something sugary to raise my blood sugar and then took a bolus to cover the carbs. Then I increased my basal dose, and haven't had a problem since.
That's a good question, Jen. I imagine that normal nutritional ketosis could add to the avalanche toward DKA caused by a several-hour loss of insulin. I speculate that it would be a marginal and additive force.
But I don't know for sure and I wouldn't want to do the experiment! Your observation is noted but I fear that urine ketone test strips are not precise enough to discern any quantitative difference. I can't defend my guess; your speculation is as good as mine!
I think you're right Jen. I mention 300 mg/dl because that is the BG level that Abbott's Precision Xtra meter package insert uses as its warning about DKA.
I wish I'd had blood ketone strips at the time, I'd be curious to know what my blood ketones were. The highest blood ketones I've had was 1.8 (normal being 0.5 or under). My blood sugar was 300 at that time. I do agree that the urine strips are incredibly inaccurate compared to the blood test strips.
I've measured up to 1.2 using the blood ketone strips while eating low carb. My BGs were normal so I had no concern about DKA. So I know that nutritional ketosis can range up into the ketone "concern" range and still be benign.
I tested a few times when I was eating 50g of carbs a day, and was always around 0.3 to 0.6 or so. The 1.8 wasn't when I was eating low carb, though; it was once when I attempted to swim for an hour with my pump disconnected. I've since stopped trying that because, even with a bolus right as I finish, it always results in really high BG and ketones and feeling sick afterward.
Some tslim tips on how to prevent bubbles learned by 2 years of use.
Use room temp insulin for all fills. Cold insulin causes champagne bubbles so pull it out and let it warm up for a few hours. Once you've done your fill it goes back in fridge.
Do not bubble air through insulin in vial when adding air to vial, and when you let the pressure push insulin into syringe do it slowly. The less banging/tapping you do the fewer bubbles you generate.
When you insert the insulin into cartridge do it in slow motion as well. Think of high pressure hose vs slow trickle, less of a head of foam if sits low pressure trickle.
You can pre fill your cartridge and then let it sit upright while you take your shower. Then go through the cartridge change steps and put on filled cartridge. Set the pump upright and have the pigtail and tubing pulled upright. I use two shelves in my supply closet. Pump on lower, tubing pulled up and over a hook on the upper shelf. It holds the pigtail vertical. When you go through the change steps just say next as you go through the steps. When it does the remove air step will prime into pigtail. Be very sure you leurlock hub is tight end fully, as that where most bubble issues happen. While the tubing primes I'm doing my site change.
Banging the pump and or flicking the hub make bubbles not removing them. If you get a bubble in hub a day later it is ok. Hub is designed to trap small bubbles so they do not go down line. When you get long bubble frequently is from loose hub so be sure you tighten completely.
You will get this worked out. Do you have Think Like a Pancreas by Gary Scheiner or Pumping Insulin by John Walsh? Both are good for how to's. Breaking basal down into steps is good rather than doing all at once for a full 24 ,hours, fasting that long can confuse the issue sometimes.
Also sounds like you need to look at DIA, correction factors and IC ratios. Do you CGM? Will help make testing a lot easier if you do. Getting the DIA set for your personal response to the insulin you use helps a lot with all the other settings.
Both books show you how to check and to find insulin sensitivity/correction factor. Then its on to finding your IC ratios which can be reinforcement for time of day.
Love the tslim programmability, give me a shout if you want more details. Happy to help you work through this.
Thanks for the pep talk!... I don't think being sick or whatever is going on in the middle of this transition is helping me- I don't trust my instincts right now. I was so dizzy yesterday I had to get off the phone, I thought I was hypo but I had climbed up to 149 which doesn't usually make me feel that bad. My tandem trainer has type 1, she said the pump got her through 3 pregnancies, and my cde's son has type 1 so they have the experience. I started with .3 and we have added .34 for dp from 4-9am. I think I may need more but some days I go hypo while I sleep and others I spike up- it is never predicable.
I had another incident tonight with an occlusion warning stopping insulin delivery which stopped half my dinner bolus. I wasn't sure what to do but I checked the tubing and then bolused the rest on quick bolus.. Then dexcom decided to go crazy and said I was going from 55 to 170 double arrows up!!! I can't believe this is all happening in my first two weeks. I must be cursed, or maybe that happens to everyone? I hope not, lol. I need a glass of wine, I felt better on mdi with a glass of wine with dinner for sure. I will post my basal test numbers below somewhere hopefully :-)
Thanks Lemonz, I will ask my cde what she thinks about this. My basal numbers were great on the test so they said stop testing and it seems that is the right rate for me but the ketones do concern me. I had low levels again today on one test. I'm not sure why I never had them on mdi- I only tested for them 1-2 x when I was sick/high.
Yes it is all included Jen. My instructions were to automatically change the set if you're above 250 and there is any sign of problems like occlusion alerts.
Thanks Hobbit, My site changes are never when I take a shower unfortunately but I will try your technique if I can figure out how to do it. I have been using room temp insulin which one of the tandems reps asked about. I had it out overnight so I'm sure whatever happened wasn't from cold insulin.
So far I'm using penfills which are for my novopen junior because I don't want to waste them. I don't have vials yet, my trainer said it is easier to avoid the bubbles with vials. She told me not to inject air- just pull the insulin out to the dose I want but I always get a big bubble no matter what technique I use- I'm injecting out any air- I hold it up to a light now to make sure. I'm going to inject more slowly into the cartridge that sounds like a good idea.
I have tightened the luer lock really tight, my trainer said to tighten it each day when I take the pump off to shower. I did notice that it seemed be looser on one occasion but I'm not sure how that could happen since I make sure it is "really" tight when I do the whole new cartridge/inset process. Maybe when I sleep or have it in the passport case I keep it in.
So basically you fill the cartridge first and then attach it to the pump? I didn't know that was possible since it guides you through all the steps and I seemed to have gotten locked out of the menu twice when I didn't do things quickly enough. Does letting it sit for a while get rid of any possible bubbles?- sounds like a good idea.
I have think like a pancreas and I have done those: my i:c is usually 1:10, although my endo changed it to 1:15 for beginning the pump and due to my lows with meals- it's now 1:12 but I think I need more for some foods, My correction factor is 40-50 points for 1 unit but again that varies a lot and I never know when or why, so they have changed it to 70 for now. My bg target was also changed from 90-100 to 120, but I have set that back to 100 now. My insulin duration is set for 4 hours but again sometimes I have experienced it lasts longer in me.
Yes I have the dexcom but sometimes it is off by 50-100 points and sometimes it goes totally crazy like tonight, in which case it is more of a hindrance than a help unfortunately. I think I need to change this sensor for sure.
My cde said 23 hours was too long because it can later cause a raise due the long fast, but I was stable till the end and then went mildly hypo so I stopped it. They said I don't need more basal testing, but I think I will do a 12 hour one when I feel better or maybe a shorter one. I find the food too close to the fast seems to affect them for me and it is just easier to fast for longer periods. I a nocturnal schedule most of the time so my whole body clock is a bit off.
Thanks for all of your input and help :-) I will ask for more if you have time I'm sure.
That's what I was thinking too Jen, if you had them already from diet would then getting sick cause them to build up more quickly. I bought ketone sticks 1 day before I was diagnosed and had the darkest color, I was already in dka then but I had no idea what it meant. I'm not sure why I did that, because I knew by that point something was off with my bg and that was one of the available otc tests. I should have bought a new meter too.
I'm going to do that Jen. I will call and ask for the rx tomorrow as well as for some insulin in vials- I have to see when I can next get insulin. I agree the strips are much more accurate, my cde said that too when I spoke with her. I had planned to get them after I got out of the hospital but then being on mdi I became more relaxed about it.
my guess..
If you weren't high before,~220 then 130/5's were possibly diet ketones from not eating.
Eating carbs/fruit without bolus is normally wrong when you are already high
do you have sickday rules?
these are mmol, but you can ask for mg/dl
Sick day rules
Sick day rules
http://www.diabetes-support.org.uk/info/?page_id=141
http://www.diabetes-healthnet.ac.uk/Documents/Uploaded/Leaflet_-_Si...
https://www.ispad.org/sites/default/files/resources/files/ispad_gui... children
Sick day rules flowchart
http://www.leicestershirediabetes.org.uk/uploads//documents/Type1 S...