520!

If your BG is over 270 then you are doing damage to your kidneys regardless of whether you are spilling ketones or not. High BGs cause all kinds of stress and related processes to go on in your cells, but this is related to the high BG level and not the presence of ketones ... Ketones are bad because they can indicate that a high is more serious than "just a high," or in other words that your body has such a severe lack of insulin that DKA may develop. DKA or diabetic ketoacidosis is when your body burns fat at an uncontrolled rate and ketones build up in the bloodstream and essentially turn it acidic. DKA is life-threatening and needs to be treated immediately or it is eventually fatal. A high blood sugar accompanied by high ketones is FAR more dangerous than a high blood sugar alone because of this risk of DKA. Ketones should be checked in the case of an unexpected high (for pumpers) to make sure insulin delivery hasn't been interrupted, and for illness or highs that won't come down (for eveyrone with diabetes) to make sure DKA isn't developing. Being a pumper, I am quite familiar with high BGs and the importance of testing for ketones. I've just never read anything that says that ketones indicate kidney damage—everything I've read and been told is that testing for ketones is important to avoid DKA. Spilling protein in the urine indicates kidney damage, but this is completely different from ketones. Do you have any references I could check out?

It seems he's heading down now, so I think he's probably okay. :)

That is a scary blood sugar. Glad to hear you're doing better. As a T1 I'm used to Insulin and you can get used to it too as part of your daily routine.

If you're a Type 2, forget about ketone testing. Type 2's who are eating normally don't develop ketones unless they're in Hyperosmolar Hyperglycemic Coma (HHC), and even then there is only a small amount of ketones. There is no nausea or vomiting associated with it, either. This coma is totally different from DKA, and the Type 1's who are telling you about DKA are giving you irrelevant information.

If you are a Type 2, and your BG is that high, and you can't get it down, then you need to go to the emergency room.

However, if you take a REASONABLE amount of insulin (and for you, 30 units may have been reasonable; it's too early to tell), and it starts coming down, then continue to monitor, and take more insulin as needed to SLOWLY bring your BG down. Extremely high BGs cause all kinds of electrolyte imbalances because dehydration upsets the way various minerals are stored, whether in the cells or in the blood.

You are right to drink a lot of fluids, but have your wife continue to watch you overnight, just in case you should develop a complication like rapid heartbeat, confusion or low blood pressure or just plain don't feel well. It probably won't happen, but better safe than sorry. If your BG has been that high for several days, then you are metabolically screwed up, and that doesn't go away even when your BGs begin to drop. A too-rapid drop in BGs can result in other metabolic complications.

I think you should call your doctor in the morning in any case. S/he should know what happened, and you should talk about how to prevent such a high BG in the future. At that BG, you COULD have gone into a coma, and you COULD have died, and the mortality rate for HHC is significantly higher than for DKA.

And yes, you should have been very worried, but I hope it's getting better by now, and please, don't do it again!

Hi!

You've been given some good advice here, but to the people who are saying "oh my god! you went high! go to emergency!", I really think this is overreacting. If you feel REALLY crappy, then by all means go. Highs are not good, but they happen, and if you feel relatively OK, then you are OK! Just take your insulin, don't take too much at once but monitor for a while after your initial dose and take more, in smaller increments, if the first dose wasn't enough. Drink water, that's good. If you feel OK to move, then do that a little teeny bit. 'They' recommend against exercise when you are high, but personally I find that moving helps the insulin to circulate. I myself am a T1 with insulin resistance/hormone issues and go high a lot no matter how hard I try to control it, so I know what it feels like, and I know my insulin never works better than when my muscles are moving it around.

As for the insulin compliance, that's all up to you. I can't tell you how to think or feel about it. I personally don't mind insulin; it's a quick thing I do to fix an issue, nothing more. It's the other side effects of diabetes that get annoying, but again I have a lot of stuff to live/work for in my life so I press through it.

Good luck! :o)

You asked advice ,here goes : learn , read all about diabetes , be compliant with your meds and insulin use...insulin can be a very dangerous drug if under or over used .Poke your finger regularly ...at least before meals , after meals , when you get behind your steering wheel .Keep records .Follow up with your Health Team. Accept you have diabetes ...unless you like to be worried for the rest of your maybe shortened life ...my simple advise .

I have to say I totally agree with you. Although DKA should be taken seriously a BG of 520 in and of itself is not necessarily immediately life threatening. . I have seen some people with diabetes be in quite severe DKA with a blood glucose of 300mg/dl while I myself do not produce ketones at 450 mg/dl (I am a type 1). I certainly think it is worth anyone's time to get some ketone sticks to see what their usual "tipping point" is. I also think the severity of DKA is also a product of how long the blood glucose has been that high. By and large if you are in DKA there will be no question as to if you need to go to the ER or not- you will feel badly enough you will just go.

I see Type 2's in the hospital in DKA occasionally. Not all that common, but DKA is real threat for Type 2's as well.

Was it DKA, or was it HHC (Hyperosmolar Hyperglycemic Coma)? A lot of people don't know the difference, and call all diabetic comas DKA, but in the Merck Manual, it says that Type 2's do not have a propensity to DKA, except in Type 1B, which is sometimes called Ketosis Prone Type 2.

I was told that, too, when I took my first diabetes education class. But I've done a lot of reading since then, and while it is true that Type 2's on the verge of HHC will show trace or small amounts of ketones, it's not the same thing as the high amounts shown by Type 1's. If you were in DKA at diagnosis, I would wonder if you weren't really a LADA -- have you been tested for antibodies? Although not all Type 1's themselves show antibodies, DKA points to an almost total lack of insulin production, and early stage Type 2's usually have higher than normal insulin production (even if it isn't very effective). Do you know what your BG was?

For Type 1's, BGs over 250, and feelings of nausea, vomiting, stomach pain, sleepiness, and rapid breathing (called Kussmaul respiration) indicate the presence of ketones and possible progression to DKA. In Type 2's, there is thirst, urination, hunger, sleepiness and confusion, and the coma comes on more gradually. The BG is also usually higher -- above 600 is usually the case, and some Type 2's have had comas with BGs of 1000 or 1500.

The exception for Type 1's is when they are first diagnosed, they can have very high BGs -- I heard of one person who had a BG of 2100 -- but the symptoms are the same.

HHC has a significantly higher mortality rate than DKA. However, the treatment is basically the same -- get the BG down gradually while keeping track of electrolytes like potassium, chloride and sodium to make sure they are neither too high nor too low. Either high or low potassium, in particular, can kill you.

Anyway, I'm glad you recovered, and are here to talk about it! :-)

When I had my coma in September, my BG was in the 500's -- 600 at the hospital. There were only small ketones, and I was deemed to have Hyperosmolar Hyperglycemic Coma. This is the most common coma that Type 2's get, and since Scott said he was a Type 2, this was a much more likely scenario than DKA.

A Type 1 can present with small ketones if he has been taking insulin to get the BG down, but it's still a different ducky.

Yes I am aware of the difference. Whether or not it is "1B or ketosis prone Type 2" would be diffucult to say as I am not aware of a specific clinical way to differentiate between this and regular type 2 that would more than likely present itself as HHNKS. If you have a way to tell the difference I would be interested to know what that is. All I can say is that I see DKA in Type 2's more often than you can explain by happenstance.

While I agree with you that HHNKS is the more likely end product for a type 2 with hyperglycemia I think it would be unwise to disregard DKA completely.

As for the type 1's, for me (not saying this is what is the norm for all type 1's) the confirmation that no ketones were spilled at 450 mg/dl came from a missed lunch bolus so there was no insulin "on board" besides basal given through the pump.

Although certainly not the case in all circumstances I see that often times DKA presents as prolonged hyperglycemia.

As a side note I once saw a Type 1 who had an A1c of 19% present with a lab confirmed glucose of 650 mg/dl with no ketones whatsoever. I puzzled over this for some time. I dug a litttle deeper and found this patient had a BMI = 13. This person had no fat to burn!! Goes to show not all people will present as would be expected.

See my reply to Emmy's message below. Are you a nurse?

As far as treatment of either DKA or HHC (also called HHNKS, as you said) goes, there is really no difference, but the presentation is definitely different.

Type 1b and Ketosis-Prone Type 2 are the same thing.

If I saw an ostensible Type 2 in DKA, I would suspect something else was going on, unless it was a long-term Type 2 who truly had very low to no insulin production.

When I had my coma last September, which was HHC, I didn't get appropriate care until my CDE told them I was a Type 1 -- basically, she saved my life. I'm actually NOT a true Type 1, but I will take whatever I need to get appropriate care.

I understand that Type 1b and Ketosis prone Type 2 are the same but what would allow me to differentiate between those and a regular type 2's besides the presence of moderate to large ketones? I guess is what I am asking is what is to say it is these individuals are true Type 1b versus an overall pattern of DKA in regular Type 2's?

I am not sure where you hail from but in the practice I am involved with there is a larger number of Type 2's, who have little to no insulin production as confirmed by a c-peptide lab draw (required by Medicare to be approved for an insulin pump), than there is Type 1's.

I am glad that your CDE was there to "push" appropriate care for you. I hope I can provide the same service if the opportunity presents itself.

As to your post below I would again caution against Type 2's disregarding ketones vs. just paying attention CBG results with the main concern being HHNKS. There are enough Type 2's out there with little to no insulin production, that to disregard ketones would be a mistake. MOST early stage Type 2's will not present with glucose in the 500+ range. Most (not all) who present this way will have a deficiency in insulin enough that they will require exogenous insulin to adequately control their DM.

Many people are misclassified as T2 because doctors expect T1 to be a juvenile disease. How sure is your classification as T2? Do you had a negative GAD antibody test?

Hi - I am a Type 1b. As I presented in DKA (BG of 30+mm/ol or 540-ish, A1C of 20+) I was first diagnosed Type 1. I was spilling huge amounts of ketones and my blood was vinegar. They didn't find any antibodies later so I was re-classified. Type 1bs/KPT2s tend to be persons of colour; all the ones I know of are anyway.