Stumped by strange, stubborn highs

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1

Last night was one of those ??WTF?? nights. Here's how it went:

We were at Cub Scouts at 6:30, and as always, it was mayhem. Eric was running around with all the older boys having a ball, but as usual, his BG took a nose dive after only about 15 minutes. And as usual, I had come prepared, and gave him a juicebox as soon as I saw the double-down arrows on his CGM. Because there was still more running even after the juicebox, when snacktime rolled around (and his CGM was still showing a slide), he had not one but TWO cookies and a cup of juice, and I gave him the juice carbs as freebies. At bedtime an hour after we got home, he was at 96, so I figured I'd been right not to cover the juice. But by 10:30, his CGM showed a steep upward trajectory, and I thought, well, maybe I should've covered him after all. Tested, found him at 286 — yikes! — and corrected.

Midnight rolled around, and I checked his CGM to assure myself that his correction had done its job. But no; the CGM still showed him in the stratosphere. Well, CGM isn't always right, so I took a BG, but it too showed him to be exceedingly high — 389. The correction, obviously, had failed to go in (although somewhat to my surprise, he had no ketones.) So this time, I corrected with a syringe, figuring if there were no ketones, he must be getting SOME insulin through the site, so I could rely on the syringe correction to bring him back down and start a new site in the morning.

Here's where it gets weird. At 3:30, I was awakened by the CGM alarm. Looking at the graph, I found he was *still* up near 400 — the dose I'd given him at midnight hadn't done a thing. The insulin vial was still well within its lifetime — I had opened it February 9th. Why hadn't the correction worked? I calculated out another correction bolus and again delivered it by syringe. And this time, I stayed up to watch the results. Sure enough, within half an hour, I started to see a downward line on his CGM. By 6:00, his CGM had him at 250. By 7:15, he was at 188.

I can't for the life of me figure out what that was all about. I can only imagine two possibilities: one, he was either so insulin resistant from the combination of night-time hormones + high BG that my first correction wasn't enough to override it, or two, somehow, I didn't get the insulin into him when I corrected at midnight. Maybe I didn't get the needle into his skin, or maybe I pulled it out too quickly and the insulin didn't go subQ. It's a puzzle. Guess I'll have to chalk it up to experience.

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Hi Elizabeth. Congratulations on doing a great job of trying to correct his low and then his high BGs. You didn't say what type of pump Eric is using, but it doesn't really matter. Except after reading your adventure with this high BG episode, is it possible that the infusion set or pod became lightly dislodged and interfered with insulin delivery becfause he was playing around? The reason I ask is because his BG was low earlier in the evening and the last bit of insulin he received was doing its last bit of work at 10:30. These high BG corrected quickly when you gave him the insulin by syringe. Did you end up changing his infusion set/pod that morning?

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sorry for your rough night! i'm thinking maybe the same as maria, did you need to change his pump in the am? sometimes jacob will have a big rebound after a low, that could of been part of it to, strange that he didnt go down with the shot though perhaps he was pretty insulin resistant at that point and he needed alot more. i hope all is better today and you got some rest, hang in there! amy p.s. looking back at your post i bet the fat in the cookies had something to do with it depending on how big they were it probably didnt kick in until around 1030. so complicated....

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My doctor would have blamed it on somogyi (spelling?) effect, but I am not sure if it actually exists or not - where you get a rebound effect from low BG. If it does exist, I think I only experience it when I have severe symptomatic lows.

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Yes, Somogyi effect does exist. And it was the first thing I thought after reading Elizabeth's post. The most common cause of Somogyi effect is taking too much insulin so BGs drop to low levels like less than 60 in the early morning hours. Then there's a rebound effect where the body's hormones that raise BG kick in to compensate for the low BG reading. In this case Elizabeth said the opposite happened where Eric's early morning BGs were very high. If the opposite had happened--his BGs were in the 70 range and decreasing, then, you're right that it was a rebound effect of a low due to his activity. Hope that makes sense!

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How much did you correct with the syringe? Also, how new was the sensor?

My guess would be that the sensor went a little wonky and he wasn't really dropping as steeply as it said, which would mean that any bolus was just to cover the carbs.
My mom and I have often found that it's hard to get my blood sugars up or down after a certain period in the evening, so maybe that's what was going on...maybe.

Hopefully you won't have to go through an ordeal like that again anytime soon.

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Eric's on a Medtronic Paradigm 522. I did think that the problem was a bad site, and that's why his second bolus (at midnight) was given by syringe. It's the fact that the second bolus didn't actually DO anything that had me stumped. The midnight bolus was 1 unit — the pump actually called for 0.9 but I can't measure in 0.1 intervals so I gave him the whole unit and figured I'd dial back his basal if he started to drop too low. The 3:30 a.m. bolus was a unit and a half. I am really starting to think that maybe I just didn't get the midnight bolus into him, for some reason. Maybe I hit some scar tissue in his bum. I changed the site the next morning and he had a crimp in the cannula, as expected.

I've seen the Somogyi effect after Eric has had a couple of bad lows. This wasn't the same thing. I think Jacob's mom is right, the cookies had an awful lot of fat in them and most likely, I just didn't bolus enough to cover them and they kicked in late.

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Oh, and the sensor was pretty new, and it was dead-on accurate as far as the drop was concerned — I didn't say so in my post, but I *did* take his BG after seeing the CGM go double-down, so I could be sure it wasn't feeding me a pack of hooey. It wasn't.

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Hi Elizabeth, just glad the bad night didnt continue into a bad day! jacob had a bad site? last weekend and was stuck in the 200's low 300's all day sat into sunday am once i changed his pod he turned around, of course he was stuck at 300 when i needed to leave him alone for an hour to teach a yoga class, talk about the yoga teacher being stressed, he's competent and responsible and his brother was with him but .... anways once the crisis is over we realize we can handle anything, we have to, we have no choice! but sharing stories lessens the load! have a good week amy

10

Know what you mean. Drives me crazy when you change the site, open a new bottle of insulin, check for bubbles, etc., ad infinitum, and you *still* can't figure it out. We've got an endo visit tomorrow so I guess I'll see just how those damn highs have impacted his a1c... ah well, can't win 'em all.

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isn't it crazy you feel like you are getting graded on your diabetes management! best of luck at your visit! amy

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My endo has a wicked sense of humor. He commented in passing that we can't seem to get his a1c down below 7.5 and I said, maybe a smidge defensively, "It's not for lack of trying, believe me." He got this wicked glint in his eye and said, "Oh, you're just being lazy! What's wrong with you? it's so easy, why aren't you doing ANYTHING about this?" I flipped him the bird. He laughed.

13

hi elizabeth, glad you are so close! you are lucky and so is eric! i think 7.5 is great, kids are hard with all the variables, jacob usually ranges between 7.2-7.8 his last was 8.5 thanks to omnipod issues but i think we have ironed most of that out, all that we can anyways!

14

I didn't much care for being needled at first, but once I got to know him, I realized that personality-wise, he was no different from Eric's dad, and my irritation stemmed from having to deal with the same wise-■■■ personality in a setting where I didn't expect to. Once I had that ah-ha moment (and also, once we started writing together), it stopped being a problem. Now I dish it right back to him and we get along great.