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Question:

From New Jersey, USA:

My six year old has type 1 diabetes. She gets 5.5 units of Lantus daily. She gets one unit of NovoLog for every 25 grams of carbohydrates for lunch. One day, before lunch, at about 11:20 a.m., her blood sugar was 225 mg/dl [12.5 mmol/L]. She then had her insulin shot and ate 44 grams of carbohydrates for lunch. At about 3:00 p.m., her blood sugar was unusually high at 483 mg/dl [26.8 mmol/L]. Do you think it is likely that she got too little insulin at lunchtime? We believe that 483 mg/dl [26.8 mmol/L] is an extremely high blood sugar and not a safe blood sugar level. Is that correct?

Adults watched her all afternoon and she did not eat anything that she was not supposed to. Fortunately, she never snacked much anyway and cheating has not been an issue for her. She was not sick and not stressed. She got the typical amount of exercise that day. Her insulin was not old. She just had a check-up and they said she was doing fine. She was not running high that week. Her pediatric endocrinologist and diabetes nurse did not recommend a change in insulin dosage after this 483 mg/dl [16.8 mmol/L] blood sugar and did not explain what caused it.

The only causes of severe hyperglycemia that we are aware of are too many carbohydrates, illness, less exercise than usual, stress, old insulin, and too little insulin. And, typically when my child is stressed or upset or crying, her blood sugar drops and she goes low (below 80 mg/dl [4.4 mmol/L), not high. So, by process of elimination, we thought perhaps the cause of the 483 mg/dl [26.8 mmol/L] blood sugar was too little insulin at lunch that day. The insulin was given by another person.

My child's total average blood sugar for the week of the 483 blood sugar was 195 mg/dl [10.8 mmol/L] (if you don't include the 483 mg/dl [26.8 mmol/L]) or 207 mg/dl [11.5 mmol/L] (if you do include the 483 mg/dl [26.8 mmol/L]). Even if you use the higher average of 207 mg/dl [11.5 mmol/L], the 483 mg/dl [26.8 mmol/L] blood sugar is 147% above that average.

Her average blood sugar for the week before the 483 mg/dl [26.8 mmol/L] blood sugar was 235 mg/dl [13.1 mmol/L]. The 483 mg/dl [26.8 mmol/L] blood sugar is 110% above that average of 235 mg/dl [13.1 mmol/L]. Her average blood sugar for the week of the 483 mg/dl [26.8 mmol/L] blood sugar was 207 mg/dl [11.5 mmol/L], using the higher average, and the average of the week before (235 mg/dl [13.1 mmol/L]) is 221 mg/dl [12.8 mmol/L]. The 483 mg/dl [26.8 mmol/L] blood sugar is 118% above the two week average of 221 mg/dl [12.8 mmol/L].

Her average blood sugar of the week following the 483 mg/dl [26.8 mmol/L] blood sugar was 172 mg/dl [9.6 mmol/L]. The 483 mg/dl [26.8 mmol/L] blood sugar is 181% above that average of 172 mg/dl [9.6 mmol/L].

Her average blood sugar of the week of the 483 mg/dl [26.8 mmol/L] blood sugar (207 mg/dl [13.1 mmol/L]) and the following week is 190 mg/dl [10.6 mmol/L]. The 483 mg/dl [26.8 mmol/L] blood sugar is 154% above the average for these two weeks.

Her average blood sugar for those three weeks (235 mg/dl [13.1 mmol/L], 207 mg/dl [13.1 mmol/L], 172 mg/dl [9.6 mmol/L]), is 205 mg/dl [11.4 mmol/L]. The 483 mg/dl [26.8 mmol/L] blood sugar is 136% above the average blood sugar of these three weeks.

Her average blood sugar for that entire month is 195 mg/dl [10.8 mmol/L]. The 483 mg/dl [26.8 mmol/L] blood sugar is 148% above that average of 195 mg/dl [10.8 mmol/L].

We are just trying to understand what caused her blood sugar to go up to 483 mg/dl [26.8 mmol/L] that day. By process of elimination, we thought perhaps she got too little insulin at lunch this day. Do you think it is likely that she got too little insulin at lunch this day?

Answer:

Overall, those averages are quite high most of the time so that there is some mismatch either in target goals, insulin to carbohydrate ratios, basal insulin or some combination.

Nobody can specifically tell you what happened that particular afternoon. You list all the obvious possible explanation. The one that is most likely with someone new giving the insulin dose is either an inadvertent error (drawing up too little insulin) or an error in administration (i.e., some leakage). Nobody would "acknowledge" such errors since they are not intentional, but when we have our nursing staff or camp staff actually observe insulin dosing, there are numerous errors occurring all the time. In addition, even if counting carbohydrates, there are some carbohydrates that require more insulin than others (i.e., rice, corn, potatoes because they are relatively simple and therefore higher glycemic indexed foods) versus others where more fiber and/or fat is also included and therefore they need less insulin, gram for gram.

A single isolated high value, even a very high one like this, is a reason to be a good detective and try to figure out the cause so that it is not repetitive. But, with corrective doses working, it is likely an isolated "error" and not so worrisome. More important is the persistent higher blood sugars that give you. That's where I would spend my "detective" time... working with your diabetes team.

SB

DTQ-20060703145221
Original posting 10 Jul 2006
Posted to Hyperglycemia and DKA

  
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Last Updated: Tuesday April 06, 2010 15:10:08
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