November 11, 2005
Hyperglycemia and DKA
Question from Land O Lakes, Florida, USA:
My son has been a diabetic for almost three years. He had one year of shots and two years on the pump. His A1c was 6.1 the last time we had it done. We usually have no problem keeping his blood sugars around 100 to 110 mg/dl [5.6 to 6.1 mmol/L] when we are home. The problem is when we go to a restaurant. You are at their mercy because you have no idea what they have cooked the food in or how it was prepared.
Last night, we went out to eat and ordered chips and salsa to start and then my son had a children’s rib basket with french fries, baked apples, and strawberry lemonade. His level was 127 mg/dl [7.1 mmol/L] when the meal started. We bolused him three units at the end of the meal because we thought that the lemonade would bring him up fast. When we got home, I had to change his site. An hour later, he started feeling bad. He was 57 mg/dl [3.2 mmol/L] and it took me two hours of testing him and giving him juice to get his level to 95 mg/dl [5.3 mmol/L]. Normally, he might do this if he has had a lot of exercise, but he hadn’t. At midnight, I tested him because I knew his food would kick in and cause his level to go up. I tested him every hour until 5:00 a.m. and he was consistently above 300 mg/dl [16.7 mmol/L]. I gave him about two units every time I tested him. I even changed his site and changed his insulin. Can the oil that the chips and fries were cooked in cause his food to digest so slowly? Or, was this a rebound from the low blood sugar? Could it have been a combination of the two? We have had food digest slowly before, but I never had to stay up all night and keep testing him and giving him insulin.
Answer:
I think that you are probably right. It is well shown that fatty foods inhibit or slow digestion (that’s why fats are so satisfyingly filling). Whether this was the explanation for your son’s troubles, I cannot say.
I also wondered if the pump catheter or the pump was working optimally if you did not notice significantly lowered glucoses. Did he have ketones? I don’t think you noted in your question the type of insulin he uses in the pump, but I find that NovoLog and Humalog do not work as well as anticipated during the presence of ketones. I prefer to give an injection of Regular during those times.
Given the pharmacologic actions of NovoLog and Humalog, I think that I would not have requested HOURLY checks, but perhaps every two hours, recognizing that you should check for ketones when the glucose is high (I recommend this when the blood sugar is more than 240 to 250 mg/dL [13.3 to 13.9 mmol/L], but some clinicians are more lax and say when the glucose is more than 300 mg/dL [16.7 mmol/L). I presume you have a calculated “correction formula.”
Finally, some pump models have a feature that will NOT allow you to continue to bolus insulin at the doses you wish, unless you override the system. This is sometimes referred to as an “insulin-on- board” feature and is touted as a safety feature. I think it actually causes more frustration.
Your certified pump trainer, Certified Diabetes Educator, or pediatric endocrinologist may be more helpful to you to help distinguish specific issues for your child.
DS
