Sick day rules/ % how how much extra insulin to take when you have ketones?

[AlexandraMarnie89]

Alexandra you are in the higher category of the Severe protocol, so you need to do this:

T1 Sick day rules

Severe

If bg is over 13mmol/l and ketones are “moderate” or “large”
Calculate the total insulin (basal and bolus) in the previous 24 hours, calculate 20 per cent of that.
Bolus: take equivalent of 20 per cent of that daily total every 2 hours
Plus normal bolus ratio for anything you eat.
Maintain usual basal doses
Monitor bg and ketones 2 hourly.
Have 100ml of sugar-free liquids per hour.

When bg drops below 10mmol/l AND ketones are negative or trace:
Eat/drink 10-20g carb
Use normal bolus ratios
Use normal basal dose.
Monitor bg and ketones 2-4 hourly.

General notes:

During illness, if you are vomiting you don’t need to eat until you feel well enough to do so, but try to keep sipping fluids.

If you continue to vomit, cannot keep fluids down and/or cannot reduce your blood glucose or ketone levels (or if you are unsure what to do) call your GP, diabetes team or hospital as an emergency.

Thanks, exactly what I needed!

I'm using pens to bolus at the moment and manually adding the data to my pump handset so everything is logged. Unfortunately I can't do my basal through pen because I don't have any lantus - seems my doctors surgery didn't take note of the letter from hospital to keep them on my prescription.

 

[Spiker]

Thanks, exactly what I needed!

I'm using pens to bolus at the moment and manually adding the data to my pump handset so everything is logged. Unfortunately I can't do my basal through pen because I don't have any lantus - seems my doctors surgery didn't take note of the letter from hospital to keep them on my prescription.

Ouch. Your GP surgery is due for a bollocking from your hospital team. They have to ensure you have backup basal insulin as well as backup quick acting insulin, and a means of delivering both of course. Do you have no Lantus left at all?

 

[AlexandraMarnie89]

Ouch. Your GP surgery is due for a bollocking from your hospital team. They have to ensure you have backup basal insulin as well as backup quick acting insulin, and a means of delivering both of course. Do you have no Lantus left at all?

I know - they put a full block on my medication at the start of April!

I have 6 units left in a pen I've just found so not a full dose (I was on 24 split)

 

[Spiker]

I know - they put a full block on my medication at the start of April!

I have 6 units left in a pen I've just found so not a full dose (I was on 24 split)

Only 6 units left in a pen will go off quickly. So if you can't scrape together enough reliable Lantus for even 12 hours that means you have no choice but to stay on the pump really. :-(



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[Daibell]

Hi. I think you need to complain to your surgery practice manager about your prescription changes. For info I have recently had surgery and have had to increase my Basal pen shot from 11 units to 14 since the surgery a few weeks back to maintain my fasting sugar. My Bolus ratio has also gone up but perhaps only around 10%.

 

[SpikeThacker]

Do you get meters purely for ketone testing?


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i have optium neo............it takes both bm and keytones strips

 

[Spiker]

Thanks, exactly what I needed!

I'm using pens to bolus at the moment and manually adding the data to my pump handset so everything is logged. Unfortunately I can't do my basal through pen because I don't have any lantus - seems my doctors surgery didn't take note of the letter from hospital to keep them on my prescription.

Are you ok now Alexandra?

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[leahkian]

Can anyone help me out on the percentage of extra insulin you're supposed to take when you have ketones? NHS direct are pretty useless and I've ( completely unexplained) shot up to bg of 33.7 so checked for ketones and showing 4.3 feeling pretty lousy atm and really don't fancy another hospital admission for DKA so need to try and get on top of it in the next few hours

Have you got any insulin pens doctor told me to have an injection of 5 units and increase basel rate by 20%. The check bloods every hour to see if its coming down, if you start to vomit best to get to hospital asap

 

[AlexandraMarnie89]

Are you ok now Alexandra?

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Feeling a bit better but had to go in this morning as was still at 30. Have come down to 19.2 just feel shattered

 

[Spiker]

Feeling a bit better but had to go in this morning as was still at 30. Have come down to 19.2 just feel shattered

You must be feeling awful. :-(

At least your BG is coming down and you are getting good support now.

 

[Heathenlass]

How are you doing now, Alexandra ?

Signy

 

[AlexandraMarnie89]

Feel pretty awful to be honest - ketones aren't coming down and bg is back up to 26

 

[Spiker]

Feel pretty awful to be honest - ketones aren't coming down and bg is back up to 26

:-(
Are you doing 20% of Total Daily Dose every 2 hours while ketones remain moderate or higher?

 

[AlexandraMarnie89]

:-(
Are you doing 20% of Total Daily Dose every 2 hours while ketones remain moderate or higher?

No I'm on a sliding scale but it doesn't seem to be doing anything. They won't let me eat until sugars are below 15 either which I don't think is doing any good

 

[Spiker]

I'm so sorry Alexandra. The sliding scale can be very slow to work. Next time if you can try the DAFNE sickness rules it might help keep you out of hospital. Could you print them out and keep them in your bedside drawer perhaps? I know I never remember them when I need them, I always have to look them up.

I hope you are better soon and out of hospital.

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[phoenix]

This booklet produced by Joan Everrett( BDEC) and Dr Helen Lockett (consultant with interest in pump education) has a good section with a simple flow chart on what to do with high levels/ketones when on a pump.
http://www.diabetes-education.net/pdf/resources/insulin_pump_workbook.pdf

 

[AndyS]

Hey Alexandra,

Sounds like you are going through the ringer. Hope you feel better soon.

One thing I haven't seen mentioned on this thread is fluid intake.
Are you keeping a good fluid intake going? I don't have the DAFNE booklet to hand but I seem to recall that you should by aiming for at least 200ml of fluid per hour while you are still high with BG and ketones.

Again hope you feel better soon and as Spiker says maybe print out the DAFNE sick day rules, they have kept me clear of hospital since diagnosis.

All the best.

Andy

 

[Spiker]

This booklet produced by Joan Everrett( BDEC) and Dr Helen Lockett (consultant with interest in pump education) has a good section with a simple flow chart on what to do with high levels/ketones when on a pump.
http://www.diabetes-education.net/pdf/resources/insulin_pump_workbook.pdf

In summary these BDEC/DEN guidelines are to inject (not pump) a doubled correction dose every 1-2 hours until ketones are no longer present. Plus taking fluids of course. So quite different to the DAFNE Sick Day rules. Though personally I think it's easier to remember to do a double correction dose, than to remember the DAFNE rules.

 

[phoenix]

They are certainly very similar to the protocol I have from here although mine says every 2 hours, not 1-2 hours. Certainly they are insistent on using pens and not the pump in this situation. I've not been there though so, I've fortunately never had to try it out for real.
I think though it's very important to check the correction dose to use. (ie not a wild guess)

 

[Spiker]

They are certainly very similar to the protocol I have from here although mine says every 2 hours, not 1-2 hours. Certainly they are insistent on using pens and not the pump in this situation. I've not been there though so, I've fortunately never had to try it out for real.
I think though it's very important to check the correction dose to use. (ie not a wild guess)

I agree. The DAFNE rules in effect use a wild guess, a fixed quantity every two hours. It's like a DIY version of the hospital sliding scale. Having said that, it does work, and relatively quickly.

I also think 2 hours is better than 1-2 which is a bit vague and could lead to bad stacking if you corrected every hour.



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