When I first went on the pump (in 2007) one of my biggest anxieties was that if something happened overnight with insulin delivery I wouldn't notice it and would wake up in DKA. I've since had a few instances of "things" happening overnight, none of which resulted in DKA, although granted they aren't good!
Last night I forgot to refill my cartridge before bed and it ran out of insulin at 3:00 AM. I had gone to bed with a blood sugar of 5.4 mmol/L (97 mg/dl). I woke up to its alarm at 6:30 AM. Usually when my pump runs out of insulin I hear the alarm pretty soon after it starts, so it wasn't until I tested at 17.3 mmol/L (311 mg/dl) that I was like, "Whoa, how long have I been without insulin?" I had large ketones. So I refilled my cartridge and corrected and will hopefully come down soon.
I've heard of people going into DKA from pump issues, but it always seems to be getting no insulin for like 12+ hours that cause problems. Has anyone ever gone into DKA from a problem that just occurred overnight? If so, then I'll get a lot more vigilant about making sure I refill cartridges before bed! If not, maybe it will help some other newbie pumper who has that as one of their fears when starting. :)
Great questions! Looking forward to replies as its a fear of mine as well! Do you have a CGM? The dexcom has literally saved my life a few times in the middle of the night!
I have gone to bead and forgot my pump in the bathroom. About 7 hours without basal, had some Ketones but not enough to send me to the hospital. I don't think many of us go long enough without testing to get into big trouble, but in the old days sometimes I would go 24 hrs without testing with a urine test strip, I'm sure that would be a big problem with only Fast acting insulin on board.
Overnight is the one time I go for a long period without testing, which I think is why it was a particular issue for me to be nervous about. The longest I've gone without insulin (except for three units I gave myself) was five hours when I went to work one day and forgot my pump at home. I felt so sick (nausea) and my blood sugar was so high for hours (I had no way of checking ketones) that I was very close to going to the hospital. Luckily things turned around and I didn't end up going, but I feel like I was mostly lucky.
If that had happened to me, my BG would be 500+. I think I am a bit unusual, with very wide BG swings. I have one time ended up in the ER with a low (while at a lunch with doctoral colleagues and my stats professor) a long time ago. But never DKA. Though I have walked around with a BG of 600 (had to leave a federal meeting with my martinet boss there but had to go out and start pumping insulin like mad. I was near to going out that time.). These events were some years back. I try to avoid these events but stuff happens.
I think each person is different and some can go into DKA with much lower BGs, perhaps 400+?
Jen, I have a Ping and I can set the alarm for whatever amount of remaining insulin I want so I have mine set for 10 units. Usually I'm aware when I'm getting low but if not it would go off when I still had 10 units left which would avoid the highs in the morning from empty cartridge. I don't think you will go into DKA from being without insulin overnight but at least you can avoid the severe highs. Can you set such an alarm on your pump?
I do have my Ping set to alarm at 20u, so I knew the cartridge was low. I just somehow forget to refill it in my efforts to get everything ready for Monday morning.
I understand about busy lives! Do you think it would help to set it for 10 and that way you would feel a sense of "I have to fill it now!" I feel that way with my pump battery because I know it's a short period of time so I do it right away so I won't forget. (I'm not busy, just spacy!)
Thanks for posting this Jen ...are your numbers OK by now ?? !! Here is a story of someone having to be rushed to ER because of no delivery ( 3 hours )http://diabeteshealth.com/read/2012/07/31/7588/my-pump-almost-killed-me----twice/ and gave up on pumping .I am pumping since 2001 and never had a pump breakdown or any other disasters such as you are describing to speak off even if I sometimes ignore the Medtronic CGMS vibrates during the night .No doubt,we have to be vigilant all of the time ( diabetes sucks equals very time consuming !)
I would think that alot would depend on how much insulin was missed and how sensitive the person is to insulin dosages. Those with smaller basal amounts would likely get away with missing insulin for a longer period of time than those with larger basal amounts.
My son has had issues with hockey. The excitement of going to a game could cause his blood glucose to spike easily to 18 mmol/L or higher during the hour drive to a rink, without food being any part of the equation. Trying to work out how best to pre-treat this sort of an adventure, he's run the gammit of trial and error, including an attempt once early on, to simply ignore it. The simply ignore it scenario had him puking in the backseat behind me that day on the trip back home. So from start to finish, that would have been a one hour drive, 2.5 to 3 hour game and part of the drive back, less than 5 hours with an elevated BG.
Exercise without insulin would make things worse, too, so that's not surprising. A while ago I was trying to swim with no pump and was having issues with spiking to 17-19 mmol/L with high ketones (1.5 to 2.0 mmol/L, normal being < 0.5 mmol/L). During those times I was only off the pump for an hour or two, but it seemed the combination of missing insulin and exercise was not good, so these days I keep my pump on while swimming.
My blood sugar was down to 5.1 by the time I got to work three hours later. Then I ate breakfast and was 12.0 just now before lunch. I think my settings are off, so I need to adjust those.
I used to have my alarm set for 10u, but then I often found that it went off during times when it was inconvenient to change, like while I'm at work. So I like a bit of warning. What I really miss is the Cozmo which had an alarm that went off every few hours once the cartridge got low. So I could set it at 20 units and have it go off three or four times to remind me to change the cartridge. I think that's part of the reason I have a problem with the Animas one that only goes off at one time and then is easily forgotten!
I think that DKA is more related to the level of ketones than the level of blood sugar? I've heard about people going into DKA with blood sugar as low as 250 if they have a high level of ketones, and a few years ago when I was in emergency and had a blood sugar of 322 and ketones they were worried about DKA (turns out I didn't have it). I have had blood sugars of above 600 before but without ketones, and have not felt half as sick as I do with lower blood sugars but large ketones. This morning I didn't feel that bad, which is surprising because I had large ketones (second to darkest colour on the strip), which usually makes me feel sick.
That makes sense, just a different way to look at it! The reason I have zero interest in a CGM is I hate alarms! (And I'd look at the thing obsessively)
Would the insulin in the tubing not cover for some added time ?? ...at least 5 u in my short tubing .I have mine set at 20 u and I know I waste some , but so be it .Medtronic gives more than one warning, when that level has been reached ...Zoe I have my pump set on " vibrates " , ha, ha .
I don't know about Minimed, but with the Cozmo when the cartridge said 0.0 units were left, there were actually about 10 "hidden" units. With the Animas, when it says 0 it really means zero, and there's no extra hidden insulin. Maybe that is part of my problem, too!
Once I forgot it after it had alarmed me at 10 units and went out for errands and lunch. When I got ready to order lunch I looked at my Ping and it said I had 1 unit left. Needless to say I ordered salad!
Maybe you can get in the habit of checking the insulin total when you do your last test before bed - or maybe this is the only time this has happened so it's no big deal.
To answer your original question, once I woke up at 175 so I did a correction along with breakfast and when I checked 2 hours later I was at 375. I figured out when I changed my set I wasn't getting any insulin but I don't know when that started during the night. All I know is it didn't take me more than 3 hours to go from 175 to 375! I think that was the first time I really got how dependent on insulin I was! Fortunately (or unfortunately) I have very little symptoms of highs. Even when I'm up into the 300s like that I just feel dull and lethargic and sometimes I only recognize that in hindsight!
I don't get many symptoms of highs, either, unless I have ketones. I think it's ketones that really make people with DKA feel sick, rather than the high alone. I think that's how some people can run around with very high blood sugars for years thinking it doesn't really affect them.
I've had some really high readings (HI on my meter), but I've only had three times in my life where I feel like I was pretty close to DKA. The first was in university when I was still on two shots a day. I only tested about twice a day and didn't even know what DKA was! I had one day where I forgot my morning shot and that evening was something like 22 (400 mg/dl), and I felt so nauseated I was literally kneeling beside the toilet! I ended up just taking a huge correction and going to bed, and when I woke up the next morning my blood sugar had come down and I felt better. Then when I was still a new pumper I forgot my pump at home, and only covered my five hours of missed insulin with three units. When I tested at lunch I was 24.6 (434 mg/dl) and again felt so sick, though I had no way of checking ketones. My blood sugar took hours to come down, and I was super nauseated and decided that if I threw up I'd go to the hospital (due to pump training I knew what DKA was at that point). My blood sugar ended up coming down, but when I finally got home that evening and checked I still had moderate ketones. Then, most recently, about two years ago I was at an AGM where I tested at 18 (320 mg/dl) and was pretty sure my site was bad, but decided to deal with it after the meeting. (This was during my "burnout" period where I spent about six months completely burned out from diabetes.) The meeting went for over two hours, and by the time it was done the meter just said HI and I felt so sick I went home instead of going out with people as planned. I did a huge correction with a shot and when I got home two hours later my blood sugar was still 31 (560 mg/dl) and I had large ketones, and it took hours to finally come down. I think if I hadn't done a huge correction with a shot I would have been in major trouble.
I do find it crazy how quickly blood sugar can shoot up with a delivery problem, and also how quickly it comes down after fixing it. I've been having weird blood sugars today (stuck in double digits, 200+ for the past five hours) so I think I'm going to change my site early when I get home.
