View Full Version : Correcting a missed bolus on MDI
Well, it's lunch and DD is HI. Looks like she didn't get her breakfast bolus, which should have been a little over 3 units of Novolog.
When she wants to eat lunch, I know I should cover the carbs, but how do I deal with the HI since I don't know how high she is? (We use the Freestyle Flash.) I gave her a unit just to see if I can get her down from HI and have something to work with.
I want to have a plan before I do much else. Thanks in advance for any input you may have.
czardoust
06-06-2008, 12:40 PM
We treat it as a 600 because if you asume its higher, then you can overshoot the bolus. Then 1 hr later, test again and adjust according to how much insulin is still on board, and do that every hour untilt he HI turns into a number and it gets to normal.
danismom79
06-06-2008, 12:41 PM
I don't know if the Freestyle Flash operates the same as our Precision Xtra, but ours shows HI if it's above 500.
We treat it as a 600 because if you asume its higher, then you can overshoot the bolus. Then 1 hr later, test again and adjust according to how much insulin is still on board, and do that every hour untilt he HI turns into a number and it gets to normal.
Ditto - but I might wait 2 hrs to correct so you aren't stacking...
Thanks! That's what I was thinking, but what if she wants to eat? Do you let your kid eat any carbs or do you have them eat free foods?
Amy C.
06-06-2008, 12:50 PM
Give her the normal amount of insulin for the food -- that is always a given. Stacking is giving a correction on top of another correction.
I would have given her at least the breakfast insulin amount.
I would have given her at least the breakfast insulin amount.
Unfortunately we didn't know the cause of the HI when we took the BG and have since determined that even though the paper log shows the amount, the bolus must not have been given. I treated it conservatively initially because I didn't know what was going on. If we were pumping, we could just verify on the pump. (We'll be pumping Animas in less than a month!)
zell828
06-06-2008, 01:21 PM
There is an actual formula you use when a meal bolus is missed. I have it at home (from Using Insulin by John Walsh) but I am at work right now. I can't remember the exact formula off hand. If you have that book, it is in there. I will pm you with it later tonight if you just want it for the future.
This happened to my SD at school once. She went to get checked for lunch, she was low so they gave her juice, then sent her off to lunch without insulin. At 3:00 pm when it was time for snack, she was obviously in the 300's then and they just did a normal correction amount for her. This was obviously too much and it sent her into a low within an hour. I did my research then and found the formula in the Walsh book they should have used then for the missed bolus instead and I emailed it right away to the school so they could have that in their files (hopefully not giving her insulin won't ever happen again though).
I'm glad I was conservative and only gave her one unit. She's 244 two hours later with remaining IOB.
Great! Phew! To answer the food question, I would let her eat.
twodoor2
06-06-2008, 04:20 PM
There is an actual formula you use when a meal bolus is missed. I have it at home (from Using Insulin by John Walsh) but I am at work right now. I can't remember the exact formula off hand. If you have that book, it is in there. I will pm you with it later tonight if you just want it for the future.
This happened to my SD at school once. She went to get checked for lunch, she was low so they gave her juice, then sent her off to lunch without insulin. At 3:00 pm when it was time for snack, she was obviously in the 300's then and they just did a normal correction amount for her. This was obviously too much and it sent her into a low within an hour. I did my research then and found the formula in the Walsh book they should have used then for the missed bolus instead and I emailed it right away to the school so they could have that in their files (hopefully not giving her insulin won't ever happen again though).
Sandy,
I think the formula you're referring to is the correction formula. If you miss a bolus and it's been at least 4 hours from your last bolus, you can use a full correction. Walsh states to always use a correction to bring down a BG from a missed bolus, and not the I:C ratio that you would have used for the missed bolus. That is because even an hour later, the food is being absorbed and the I:C ratio will not have the same effect on the carbs as the correction will.
Correction formula is
(CBG - TBG)/ISF
where CBG is current BG
and TBG is target BG
and ISF is Insulin Sensitivity Factor.
Coni, I missed a lunchtime bolus about two weekends ago, and my daughter went up to 416 two hours after lunch. I have to say that it was a very stubborn high because
1) I'm sure it was still rising from carbs still being absorbed (she had about 57 for lunch!!) and
2) The higher the number, the more difficult it can be to get down.
I had to use a very high temp basal AND a pump correction to get it down. When you start the pump, you will find that this is very easy to do if you have a stubborn high. I'm glad you were easily able to get it down and that Esme is doing okay now.:D
Correction formula is
(CBG - TBG)/ISF
where CBG is current BG
and TBG is target BG
and ISF is Insulin Sensitivity Factor.
I thought about this, but I didn't know her current BG! My thought was to give her a little insulin so I could have a number to work with. If I had used 500 as her CBG, she should have received 2.3 units. I only gave her one unit, and she's now 147 four hours later without additional corrections! I don't know what made me be so conservative, but I'm glad I was. Very strange, but all's well that ends well...
twodoor2
06-06-2008, 05:27 PM
I thought about this, but I didn't know her current BG! My thought was to give her a little insulin so I could have a number to work with. If I had used 500 as her CBG, she should have received 2.3 units. I only gave her one unit, and she's now 147 four hours later without additional corrections! I don't know what made me be so conservative, but I'm glad I was. Very strange, but all's well that ends well...
Just some FYI: The AccuCheck Aviva has a higher threshhold for a HI reading than some other meters. I have never ever had a "HI" reading on it. When I used the Freestyle lite for a small time to test it out, I did get a "HI" reading. However, that being said, meters are more inaccurate the higher the reading, so the correction will most likely not be exact.
It's good to be on the conservative side, but note that if the number is not going down at all after an hour, it's probably still on the rise, or more stubborn. Therefore, the standard correction may not work, and you have to be more aggressive. This happened to Elizabeth the day I missed her bolus. I gave her a correction at 416, and one hour later, she was 418!! I then gave another full correction AND a temp basal, and she started coming down.
zell828
06-06-2008, 05:50 PM
Sandy,
I think the formula you're referring to is the correction formula. If you miss a bolus and it's been at least 4 hours from your last bolus, you can use a full correction. Walsh states to always use a correction to bring down a BG from a missed bolus, and not the I:C ratio that you would have used for the missed bolus. That is because even an hour later, the food is being absorbed and the I:C ratio will not have the same effect on the carbs as the correction will.
Correction formula is
(CBG - TBG)/ISF
where CBG is current BG
and TBG is target BG
and ISF is Insulin Sensitivity Factor.
Marsha, I am not positive what the formula was, I haven't had to look at it in a few months since it happened with the my SD. I will have to look at it tonight to see for sure if this is what it says, but you know so much so you are probably right though :)
twodoor2
06-06-2008, 05:53 PM
Marsha, I am not positive what the formula was, I haven't had to look at it in a few months since it happened with the my SD. I will have to look at it tonight to see for sure if this is what it says, but you know so much so you are probably right though :)
Please post it. I know I read and quote John Walsh a lot, but it's good to be accurate.
zell828
06-06-2008, 05:57 PM
Please post it. I know I read and quote John Walsh a lot, but it's good to be accurate.
Okay, I will post it here when I get home.
zell828
06-06-2008, 10:56 PM
Here it is (under 13.8 - A postmeal situation to be careful about). This is in Using Insulin by John Walsh.
http://i21.photobucket.com/albums/b281/zell828/3-4-200855953PM.jpg
twodoor2
06-06-2008, 11:03 PM
Hi Sandy,
This is just an easy table that allows you to correct back to BG of 100 using the same formula I mentioned above. All this table does is use the following formula, where the TBG is a constant of 100.
(CBG - 100)/ISF
I would rather use the formula because not everyone knows their exact ISF, and would rather be safe and correct to a higher target blood glucose.
The table above also does not account for existing IOB or the fact that the BG may still be on the rise (like from a fat spike or a missed bolus).
Thanks for posting this though. I'm sure it will help some people that are unfamiliar with the formula.:D