No, it is generally not recommended to treat high blood sugars and ketones with an insulin pump alone. When a person has both high blood sugar and ketones, it means they require more insulin than their basal rates can provide. It is safer in this situation to treat with injections of rapid-acting insulin until blood sugar and ketones start to improve. The pump basal rates may need to be increased temporarily as well. Treating only with the pump risks not delivering enough insulin quickly enough to address the problem. Shots provide a larger, faster-acting dose that is more appropriate in this medical emergency situation.

1. Keeping your child (or you) with diabetes out of the hospital
Webinar August 19, 2014
Stephen W. Ponder MD, FAAP, CDE
Baylor Scott & White Healthcare
7:30-9:00PM Central Standard Time

2. Housekeeping notes…
 This Webinar IS being recorded for future playback.
 I hope you reviewed the Prewebinar background materials I
posted to Slideshare and You Tube.
 This slide deck will be posted to Slideshare too
 Links to all resources will be put on my Facebook page:
“The Power Within by Stephen Ponder MD, FAAP CDE”
 Submit your questions during the webinar and the moderator
will collect them for our Q&A at the end.
 This Webinar will end promptly at 9PM CST
 The next Webinar is scheduled for Tuesday October 28th 2014
from 6:30-7:30PM CST: Topic “Travelling with Diabetes” by
Dr. Matthew Stephen.

3. This area of the patient/parent brain needs some help
DEALING WITH
ANNOYING THINGS
OTHERS SAY CENTRE
INSULIN AND
CARB
CALCULATOR

4. 6 things you should remember…
1) How type 1 diabetes works
2) Importance of water
3) Dual role of insulin (on/off role)
4) Most carbs become sugar
5) Exercise is a form of stress
6) Our brains run on sugar

5. Your “toolkit”…
A method to check BG
A method to check ketones (urine or blood)
Access to liquids (carb and non-carb)
Carbs (fast and slow acting)
Glucagon for injection
Insulin and a way to deliver it reliably
Anti-nausea medicine?
Your wits (and maybe a phone)

6. “The process”
1) Get the necessary facts
2) Identify immediate needs
3) Prioritize your actions
4) Do your actions
5) Repeat the cycle as needed
6) Don’t stop until job is done

7. Common problems in type 1 diabetes
 Missed insulin dose(s)
 Insulin dose reversals
 Surreptitious insulin doses
 Outdated/damaged insulin
 Changes in routine/preparedness
 Insulin pump/site/tubing problems
 Medication side effects
 Stress and infections

8. Communication/observation is everything
Low blood sugar
– Sweatiness
– Shakiness/tremor
– Loss of energy/interest
– Sleepiness
– Confusion
– Irritability/Moodiness
– Headache
– Upset stomach
High blood sugar
• Thirsty
• Peeing more often
• Headache
• Itchy skin
• Cramping muscles
• Stomach ache
• Nausea/vomiting
• Irritable/moodiness
• Deep breathing
• Stupor
Highketones
Highketones

9. Prepare for the ER/hospital

10. Role of the ER
Many health professionals
are uncomfortable/unaware
of the practical side of most
diabetes technologies.
This causes tension/stress
Still, most parents are
directed to go to the local ER
for all urgent problems, no
matter how minor.

11. Many ER docs will want to remove an insulin pump (this can solve
as well as cause problems)
IV’s in the ER are almost standard these days
Just a little IV sugar water can drive up BG
Most ER docs will not know what a CGM is
Bring additional supplies with you to hospital
Be understanding, they are only trying to help
But in ER, protocols often overtake thinking!
Withheld insulin doses in ER can happen!

12. Expect your calls for
emergent problems to
be returned in a timely
fashion…not 5 hours!
If the problem is
advanced (e.g., severe
dehydration, uncontrolled
vomiting), you MUST go
to ER, or call EMS.
But…the best
management is
PREVENTION by
knowing the sick day
rules.

13. Take your diabetes
supplies with you to ER
when possible
Ask and expect clear
explanations
Try to be calm and
collected. HCP’s
ultimately want to help.
You know your
child/yourself best.
Work with the HCP as a
team. You are the team
leader!

15. Sound vaguely familiar?
My 14 year old teen with type 1 diabetes is feeling ill.
The teen says the blood sugars are “alright”. My teen
has now thrown up twice. What should I do next?

16. a. Measure her ketones
b. Change the infusion site
c. Check for air bubbles in the tubing
d. Give her some Emetrol
e. Check her blood sugar

17. a. Measure her ketones
b. Change the infusion site
c. Check for air bubbles in the tubing
d. Give her some Emetrol
e. Re-check her blood sugar

18. a. Give insulin correction dose through pump
b. Change the pump infusion site
c. Check for air bubbles in the tubing
d. Give a shot of rapid-acting insulin
e. Give her anti-nausea medication

19. One method is to give the “correction” dose assigned to you
by your doc/team
Another method is to dose rapid-insulin based on body
weight. (e.g., lispro, aspart, glulisine)
0.1 Units/rapid insulin per kilogram weight
◦ Weight in lbs divided by 2.2 = weight in kilograms
◦ Give one tenth of that amount as rapid insulin
◦ Example: 60 pound child: 60/2.2 = 27 kg
 27 x 0.1 = 2.7 units or…3 units

20. a. Give her an anti-nausea suppository
b. Offer a trial of a bland solid food (e.g., toast)
c. Take her to the emergency room now
d. Recheck blood sugar and ketones
e. Give her another shot of rapid insulin

21. a. Repeat shot with same amount of rapid
acting insulin as the previous dose
b. Give anti-nausea medicine/suppository
c. Offer a trial of a bland solid food (e.g., toast)
d. Take her to the emergency room now
e. Use smart pump to calculate/deliver a
correction dose for 320 mg/dl (17.7 mmol)

22. a. Administer another rapid insulin shot
b. Deliver a correction insulin dose with pump
c. Offer a trial of a bland solid food (e.g., toast)
d. Stop sips of water
e. Go to emergency room since ketones are still
large

23. a. Deliver a correction insulin dose with pump
b. Continue bland foods, sips of water and give
bolus insulin for carbs
c. Go to emergency room since ketones are still
present
d. Keep checking BG but stop checking ketones

24. a. It’s alright to go back to normal diabetes
care routine now and stop checking ketones
b. Encourage fluids and check BG and ketones
every 2-4 hours until ketones are all gone
c. Increase the pump basal rate by 25% for 12
hours to eliminate ketones

25. a. 3 year old boy has vomited 6 times this morning
and won’t eat or drink, BG 412 (23 mmol)
ketones, blood ketones high
b. 12 year old girl has sharp lower belly pain and
vomiting x 3, BG 220 mg/dl (12.2 mmol) ,
ketones trace
c. 10 year old boy with nausea and one episode of
vomiting , BG 557 mg/dl (31 mmol), large urine
ketones
d. 14 year old girl who is hard to arouse. BG is not
readable on meter. Can’t get urine sample for
ketones

26. High blood sugars may/may not be associated with
ketones
The presence of high sugar and high ketones
MEANS INSULIN IS NEEDED IMMEDIATELY
Frequent sugar and ketone re-checks are key to
successful treatment
Staying well hydrated and managing nausea is
ongoing
If vomiting can’t be stopped, you must go straight
to the hospital/ER/EMS
Blood sugars improve well before ketones
disappear

27. Working on “why this happened” usually occurs as you are
treating the situation
Never treat high sugars and ketones with an insulin pump at
first.
High sugar and ketones on a pump is a pump problem until
proven otherwise

28. Ketones are not bad
• A normal part of human biochemistry
• Always present in low amounts
• Used as a source of brain energy
• Non-d people would be frequently
hypoglycemic without ketones.
Normal life would be quite difficult.

29. Unlike those scary movies...just finish off the bad guy!
Ketone man
PWD or
parent

30. If I or my child forget to take a meal time insulin dose through
a pump or shot, this will cause ketones to occur in the blood.
FALSE: At most, high blood sugar will happen. If the basal
insulin through the pump (or shot) is working, this is enough
insulin to prevent ketone production, not enough to control
the sugar rise.

31. Situation
A toddler with diabetes normally gets 5 units
NPH in the morning and 1 unit NPH in the
afternoon plus a dose of 2 U Lantus in the
evening. Father accidently gives a 5 unit dose of
NPH at 3PM. What should be done?
ANSWER: 1. Check sugars more often until AM
2. Give a larger meal for dinner
3. Give usual Lantus dose at bedtime

32. Situation
I got a call from my ex-husband in California.
Our 14 year old daughter with type 1 diabetes
spends two weeks with him every summer. This
morning he called to tell me she was up all night
vomiting. He said she told him her blood sugars
were ok. Is she coming down with the flu?
ANSWER: 1. Check BG and ketones directly
2. Get ready to go to ER ASAP

33. Situation
I just got a call from EMS about my daughter
with type 1 diabetes. Bystanders at the mall said
she was acting strange and screaming
obscenities at other people. She kicked a clerk
and someone called 911. What’s the reason?
ANSWER: 1. Low BG
2. Substances
3. Both?

34. Situation
EMS treated her with IV sugar twice. Her sugar
quickly came up to 275 mg/dl (15.3 mmol) in two
minutes, but she was still acting irrational. Why?
ANSWER: 1. Lag before sugar gets into brain
2. Substances?
3. Both?

35. Situation
Your child with diabetes also has moderate to
severe asthma. Her doctor just prescribed
prednisone pills by mouth to help with a flare
up, in addition to his other medicines. What do
you need to be prepared for?
ANSWER: 1. higher sugars
2. maybe ketones

36. Situation
At midnight my d-daughter had a severe low blood
sugar. We heard her moaning in her room. Her sugar
was 32mg/dl (1.8 mmol) and she was incoherent. We
injected her with 1 mg glucagon and called EMS. By the
time they arrived she was awake but nauseous. She
went to bed early after dinner she and her dad got into
an argument over a new boyfriend. She wears an
insulin pump. What can I do next?
ANSWER: 1. check the insulin pump history
2. review BG’s to see if changes are needed

37. Oh no. Not Mystery Boluses!

39. Situation
Your 3 year old with diabetes is very fussy and has a blood sugar
of 58 mg/dl (3.2 mmol). He refuses to eat or drink anything you
offer him. Should you take him to the ER or call EMS? What else
can you do?
ANSWER: 1. Mini-dose glucagon

40. Mini-dose glucagon
• For treating non-severe low blood sugar with
nausea, usually in younger children.
• Requires careful attention by parent/caregiver

41. Recipe – Mini-dose glucagon
• Prepare Glucagon as you normally would for a severe low BG
– 100 units diluent into 1 mg powder
• Give by subq injection:
– 1 unit for every year of age between 3 and 15
– No less than 3 units
– No more than 15 units
• Check BG in 30 minutes
– Repeat if still under 100 mg/dl

42. Situation
It’s 3:00AM and you go to check your d-child’s blood sugar. She
wears an insulin pump. The sugar is 427 mg/dl (23.7 mmol). What
do you do next?
ANSWER: check ketones

43. • Dislodged site
• Improperly inserted site
• Infected site
• Air (bubbles) in tubing
• Heat damaged insulin
• Programming error(s)
• A skipped food bolus is
NOT a reason but
certainly enables the
situation
Insulin pump debacles

44. Straight versus angled infusion sets

53. Air in infusion tubing

54. Air in luer lock hub

55. 120 U of air

56. Defective tubing connections

57. Subcutaneous layer
Muscle tissue
Dermal layer
“Tunneling”  A problem with Teflon
infusion sets
 Back-leakage occurs due to a
slightly dislodged catheter
 High BG is the only sign
 Tennis players, golfers and
other vigorous activities
 Solution: Make a tape
“sandwich”, use metal sets

58. Tunneling

59. What have we learned
Insulin pumps are complex devices and can malfunction or be
misused in different ways
Never trust a pump to treat high sugars and ketones. Go with
shots and/or new insulin
When in doubt…change it out
Uncontrolled vomiting = go to hospital ASAP

60. Situation
My 12 year old son with diabetes just threw up unexpectedly
after lunch and says his stomach hurts. What should I do next?
He is very responsible and takes his own shots.
ANSWER: have a grown up re-check his BG and ketones anyway

61. Situation
It’s an hour after lunch on the weekend. Your
teen son ate three large slices of pepperoni pizza
and took 15 units of Novolog (the most the
pump would allow). He was next door playing
basketball for 30 minutes with his friends. Now,
he’s feeling sleepy and has laid down on the
sofa. Why?

62. Sleepy after pizza? Why?
a. Pizza makes us drowsy
b. Spiking sugar levels
c. Ketones from the fat
d. Insulin-food mismatch
e. Pump malfunction

63. Situation
Your daughter with type 1 diabetes plays 3rd base on her high
school softball team. Her team has played games all day long and
advanced to the state finals. Her blood sugar at the end of the
last game today was 210 mg/dl (11.7 mmol). What considerations
should you have? She takes Lantus and Novolog shots.
ANSWER: Post exercise hypoglycemia

64. Post-Exercise Hypoglycemia
• Lows that happen well
after exercise
• Happens in up to one
third of PWD’s
• Lowering sugar
independent of insulin
• Treatment
– Increase snacks
– Reduce basal overnight
– Check BG at 3AM
Liver

65. Situation
Your 10 year old son is scheduled to have a plantar wart removed
by the podiatrist. He wears an insulin pump. How should his
diabetes be managed during the procedure?
ANSWER: No differently than anyone else

66. Situation
My 16 year old daughter with type 1 diabetes
(diagnosed 3 years ago) developed a skin
infection on her foot from an insect bite and is
now on several antibiotic pills prescribed by her
doctor. Does she need to do anything different
for her diabetes? Could this cause her to lose
her leg?
ANSWER: 1. Check BG more often
2. Her leg should be fine in time

67. First, it’s not a category in
the Guinness Book of
World Records!
Blood sugar is measured
relative to the amount of
water in the blood (the “dl”)
Higher the BG, the more
dehydrated you are.
It’s why hydration (water)
is an important first step in
care

68. Hourly at first. You want to know what direction BG is headed.
If using sensor: every 20-30 minutes check trend line
Check ketones hourly if you can (urine or blood)
Check things less often as you get comfortable that trends are
improving
BUT never let up until normalcy reestablished

69. FAQ: Can I treat high sugars and ketones with my
insulin pump?
• Maybe after improvement on
shots. But if the problem is the
pump, insulin, tubing or site,
treating with the pump would
only slow down recovery or
worsen the situation
• The safest approach is use insulin
by injection until normal. If there
is any question about whether
the insulin is bad, open a new
bottle.

70. Unexplained high,
explained…
Culprit: unremoved cap
First discovered…
Corrected all by injection
New site
carb
FAQ: Can I rely on my CGM sensor during DKA?
YES, MOSTLY

71. Potpourri

72. Why is insulin usually LESS effective when sugars are high and
ketones present
1) Temporary insulin
resistance
2) “Glucose toxicity”
3) Higher levels of anti-
insulin substances in
body
4) Dehydration makes
insulin harder to
absorb

73. Tip: Ketones clear slower than the BG can
come down
Ketones
• Are lost in urine
• Are lost through lungs
• Are converted to other things in the
liver
Sugar
• Is lost in urine for a while
• Is driven back into muscle, fat and liver
• Is burned up for energy
• Is produced less internally when insulin
is around

74. Tip: It takes less insulin to arrest ketone
production than it takes to control BG
About one-tenth as much!

75. Tip: Totally normalize sugars and
eliminate ketones before resting
Stop and remove ketones
with EXTREME PREJUDICE

76. Tip: As you treat an extreme high or low
sugar, at some point try to figure out what
might have caused the situation
But don’t take valuable time
away from treating the
immediate problem!

77. Tips: The little things overlooked
• Not discarding opened insulin
after 1 mo of use
• Avoiding prolonged exposure of
insulin to hi heat or freezing
temps
• Dosing insulin then forgetting to
eat on time

78. Troubleshooting tips
• Making too many changes on a
pump at once
• Not double checking a high BG
before correcting (false high)
• Not cleaning hands before
checking BG

79. Troubleshooting tips
• Blaming everything on
diabetes
• Ignoring pump and sensor
alarms
• Over-treating low blood
sugars
• Not filling a pump cannula
after insertion
• Priming insulin pump
tubing while wearing it

80. Troubleshooting tips
• Not having an off insulin pump
regimen or back up plan
• Not using insulin pump
temporary infusion rates for
illnesses
• Not having a source of fast carbs
within reach

81. Troubleshooting tips
• Not checking ketones for high BG
levels
• Not finishing the bolus cycle of
some pumps
• Not checking pumps for air
bubbles
• Not checking BG after a site
change to make sure it’s working The “forgetting curve”

82. Common diabetes errors
• Skipped/omitted shot(s)
• Inconsistent BG checks without
attention to what the number is saying
(over 300 mg/dl or 16.7 mmol)
• Assuming immunity to ketosis
• Intentional insulin skips for weight
loss/body image
• Lacking emotional maturity for self
care: too young

83. How often can I take extra rapid-acting insulin?
• If by a protocol, by what the
doctor recommends
• At a minimum, check BG/K
every 2 hours and act
• Some docs (me) will advise
hourly injections with hourly
BG/ketone checks and call
backs
(0.1 Units/kg body weight*)
* Weight in pounds divided by 2.2 = weight in kilograms

84. Deciding to treat at home
• No major symptoms and
alert/awake: STAY
• Perhaps only nausea: STAY
• Vomited once or twice and
able to keep trying: DEPENDS
• Appearing ill and vomited 3
times or more times: GO!!
• Not sure what to do: GO or
CALL MD

85. When to call for back up/go to ER
• If vomiting can’t be
controlled
• Can’t stay awake
• Fast deep breathing
• Twitching/seizing
• If the child/person
just isn’t “looking
right” to you
Help,
Doc!

86. Summary: Diabetes “Sick day” rules…
1. Check blood sugar often
2. Measure ketones until gone
3. Drink plenty of fluids
4. Treat nausea
5. Take scheduled insulin
6. Take extra insulin as needed
7. Know when to call for help

87. Finally…
Give yourself credit for what you do WELL!!