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Anyone care to give advice on this CGM printout?

Discussion in 'Continuous Glucose Sensing' started by Jacob'sDad, Aug 5, 2009.

  1. Jacob'sDad

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    Hi all. This is Jacob's CGM output from the last 24 hours(click on the attachment at the bottom). The green triangles are today's numbers and the yellow boxes are yesterday. So the stuff at the right end of the graph is actually from yesterday. The graph always starts at 12am.

    Here's some key events that should help it make sense.

    1) Jacob had pizza around 4pm yesterday. The climb you see starting at about 5:30pm is from the pizza. I did five corrections over the next several hours to get him back in range.

    2) There is about a 1.5 hour data gap starting at 12am. The Dex was charging and this loses range. The Receiver must be very close to the transmitter to not lose signal when charging.

    3) Half a juice box was given at 5:30am plus a two hour -20% temp basal. The other half of the juice box was given at 8:30am.

    4) Jacob had generic honey nut Cheerios at 9am

    5) Jacob had a juice at 11:30am. His meter read about 20 points higher than the CGM but I didn't want to calibrate when he was low. Jacob had another juice at 12:30pm

    6) Jacob had McDonald's at about 1pm. It included a kid's double cheeseburger meal with fries. He also had apple dippers with caramel sauce.

    7) OK, you're going to think I feed my kid garbage but since he was trending toward low at 3:30pm, which was when I got home from work, Jacob asked if he could have a $1.00 chocolate shake at the dairy store. They are kind of small. By the time we got there he was already trending up.

    I was going to put down my own feelings about these numbers, but instead I think it would be interesting to here some other views first.

    Thanks for any help!
     
    Last edited: Aug 6, 2009
  2. Jacque471

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    To me it looks like any normal day for us. Ours is always full of peaks and valleys. We just try and keep the peaks from going to high and the valleys from going to low LOL
     
  3. betty6333

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    If it were my kid... this is what i'd do.

    1.
    Drop the 2am -3 am basal by .025 or .05 depending on what that current basal is.
    Example if the basal from 2-3 is .3 i'd drop it by .025, if it is over .50 I'd drop it for that hour by .05

    Drops like that make me nervous because one heavy exercise day means that low will be even more pronounced.

    ( BTW once you get that night basal set without drops you can put him to bed in the 80-100 range!!! ) We don't put him to bed over 100 or under 80 he went to bed last night at 87 ( cgm read 83) and woke up 100 (CGM said 94)


    2. prebolus breakfast.... if you can't do the whole thing prebolus ten carbs at least then do the rest once he is actually eating.

    Also either the I:C is off at breakfast, the basals are off or the carb count was off.... run a day of basal testing during that time period before switching any other numbers around.

    3.
    You likely need a new correction factor. Pizza is always a bear, but the corrections you did had little effect, and I would expect to see a drop from aggressive corrections, even if it was the pizza causing it to go back up.

    Do you gram weight the pizza and then use the carb factor? Run a few pizza tests... meaning you feed pizza every night for a few nights till for find a I:C and % extended to cover the pizza.

    Not too bad for just starting the CGM though!! our first few weeks/months were constant trial an error in getting foods right!

    These are what I would do for my kid... it may not be the right thing for your's!!!!

    if you can check out the basal the rest of the day, it might be good too. Remember with apidra, 4 hours post a bolus if the numbers are not steady, it is time to basal test !

    You are doing great!
     
  4. betty6333

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  5. Jacob'sDad

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    Hey Betty do you know of an easier way to get these charts into a post? I printed it, then scanned it. Otherwise it's just a temp file right? and it goes away?

    BTW, I agree with your assessments. Jacob has a much higher basal in the morning and I think it's about right, but I'll bet it lasts too long. I think the carb ratio is a tad low too. I lowered it in an attempt to reduce the spike, but I think this graph is a perfect example of how some kids will spike from cereal no matter what unless you prebolus. The spike was almost instantaneous upon eating. Jacob has fast digestion and his stomach is empty. No amount of insulin is going to beat that spike. Insulin can only absorb so fast. Only prebolusing will get the absorptions to match up. I should post the morning hours graph from yesterday. No cereal and no spike. AT ALL.

    With the pizza I had to make a choice as to how much IOB I was going to ignore. I ignored it all at the first correction but with the future corrections I had to consider how much of the IOB from previous corrections was working. I mean, I can't really ignore ALL of the IOB EVERY time, right? I did total up all of the insulin I gave from dinner until he was back in range, so know I have a better idea of what to do for pizza next time.

    One other thing I have noticed is that fluctuations in Jacob's BG at night correlate very closely with changes in his basal rate. There doesn't seem to be hardly any delay. If the basal rate changes, the BG changes very shortly thereafter. The 2am basal is one that I changed yesterday, but I over adjusted.

    Your son's nighttime basals look great!
     
  6. betty6333

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    I just do a screen shot to photobucket, I am not very tech savvy!

    Here is the last 3 days of my sons numbers,This is a summary of the 3 days, I'll explain what changes we made and what we are still working on.

    With diabetes you get it right and it lasts for a while... some times a day, somtimes you get lucky and it lasts a month! but something always changes, so try not to drive your self crazy when you see great numbers for a week then need to change them all over again! Diabetes is just that way!
    http://i344.photobucket.com/albums/p323/betty6333/averages.jpg OK. now you can see just looking at the numbers, we are having a post falling asleep spike ! It has been driving me nuts for weeks, the problem is that the spike comes about 30 minutes after falling asleep and he is not falling asleep at the same time so I can't work it into a temp basal, to test to make it permanent. I tried about 2 weeks ago ... ran a temp for 3 days, and when I made the increase permanent it dropped him to 60 the next night ! MADDENING to say the least, so for now I am left with correcting ! VERY annoying! Last night he was in range , but the 2 nights before that I had to correct at different times and that is what the numbers are showing. You can see we have a breakfast spike to average 150, but it comes back into range so ... I just need to be better with my own advise on getting that prebolusing in ! We don't low carb anything, he has oatmeal or fruit loops for breakfast, with OJ and milk! We are just going to work around the food for him. I think it is great that some people get their kids to eat healthy all the time... we are just not not those people ATM !
     
    Last edited: Aug 6, 2009
  7. betty6333

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    I think it takes a long time to get a feel for how your child works. For instance with corrections, I wait an hour and a half, if he is not lower I give a FULL correction again, I have learned that at 1.5 hours, if he has not gone down there is not enough apidra left to drop him. Most people call it stacking, but i have seen how his body works to know full well that it is NOT and has never caused a low For HIM.

    I also wanted to add that you are doing a great job again, Diabetes is a tough disease, and even when you learn a lot about how to keep numbers in range, you will still be human and that is OK!
    I hope you didn't think I was trying to criticize you in any way, because I was not. I don't always remember to pre bolus! I think it looks good so far! I wish when we had started the CGM that our numbers had looked as good as yours, because they were a total mess. You are doing a great job taking care of your son, and I hope you will always remember that ! I am glad when I see parents who are so diligent and caring in their childs health. I hope that you cut yourself a lot of slack, and when you get tired and frustrated with the numbers you will remember that although we as parents strive to be a pancreas, we will never be a real pancreas. You are however, amazing!
     
    Last edited: Aug 5, 2009
  8. Ellen

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    May I suggest you redact your child's name from the image? I think detailed medical information of a child should not be so accessible to the world at large.
     
  9. Jacob'sDad

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    Done. Forgot all about that.
     
  10. Darryl

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    My only comments -

    1) Looks great, Dave!. Keep this up, and his next A1C is 6%

    2) The cherios may be high glycemic - maybe try a smaller serving next time, along with some other food at breakfast.

    3) The afternoon high looks carb stacking - when BG goes up, then more is eaten, it goes up some more. We try to avoid consecutive meals/snacks when BG is still rising. But of course BG will sometimes go over 200 no matter what you do. The important thing is that it doesn't happen routinely, or stay high for a long time.
     
  11. ecs1516

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    Same with us. Our last A1C on Monday was 6.4 for my older son.
     
  12. Danda

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    Fast stone Capture

    May I suggest, you d/l a little program call Fast Stone Capture.
    The version 5.3 and before are free for home use. The program is very handy: screen shot, take a shot of just a part of a picture or program, can save a scrolling page, etc. All shots are taken on default PNG(Portable Network Graphics), but you can choose to save on other formats from the drop down menu: bmp, jpg,tif,pdf,etc. Save to your computer(desktop, pic folder, etc), u/l to tinypic(no account needed) and voila... done. :cwds:

    Here is a better description of the program.

    [​IMG]
    [​IMG]
    [​IMG]

    I hope this help. :cwds:
     
  13. Darryl

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    Dave, how are things going since you last posted?
     
  14. Jacob'sDad

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    Well, it's been quite interesting. We went on vacation and stayed at a cabin by a lake for a few days. On the way up there we stopped at McDonald's. We hadn't been on the road long. Jacob was higher before he ate than I expected although I don't remember the exact details. After he ate his BG shot right through the roof. I was quite surprised and I corrected when it got to 350 which it did very quickly. This did nothing. In very short order he was off the top of the CGM and a finger poke showed 470.:eek:

    It was then that his brother remembered tripping over Jacob's tubing when Jacob was sitting on the floor at home right before we left. I checked the site and although at first glance it looked good, closer inspection showed that the steel cannula had been pulled right out of his body. I don't know how he didn't feel the insulin dripping on him during boluses. I changed the site, did a huge correction, and had him back in range several hours later. I think it took a couple more corrections if I remember right.

    He did a lot of swimming and I was just glad we didn't lose the transmitter. We don't have an arm band for him so I added an IV3000. The first sensor did loosen up so I changed it. We got six days with no issues. The second one has been good too.

    He was missing a fair amount of data while swimming but we are lucky that Jacob's basal rate is quite low in the afternoon, which is when he did most of the swimming. He disconnects from the pump and usually requires one juice to keep from going low.

    Overall we've still got a major breakfast spike that occurs immediately after breakfast, if breakfast is cereal. So far, the kind of cereal doesn't matter. He also spikes from lunch. I think changing what he eats for breakfast might help BOTH breakfast and lunch spikes. His food is digesting too fast.

    I have also seen incredible spikes occurring many hours after eating lasagna or mac and cheese for dinner. I don't see how this could easily be bolused for. There is a big gap of like four hours where BG is fine before the spike. How can you combo bolus for that? I think the best I can do is to turn the high alarm down to 120 or 130 and then get right on top of the correction when he starts to spike.

    Overall he has been trending lower and this is reducing his overall insulin need. So, for now, constant adjustments are required. Yesterday his average BG was 115.:)

    That brings us to today, which has been a nightmare. Jacob has been high all day. I changed the site at 5pm but that only helped slightly. It is as if he needs double the normal insulin amount. I have never seen Apidra go bad, but I think I have now. This cartridge was filled before vacation and it has been hot out. When I finish this post I am going to change it. It's down to 15u anyway. His average BG today must be close to 225. Some of that occurred when I was at work. My wife hasn't gotten up to speed yet on correcting based on CGM data. I'm still learning too. He has had 44u of insulin today and the day ain't over yet.:eek: His normal TDD is about 30u.

    Sorry for the long post, but thanks for asking about Jacob.
     
  15. betty6333

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    Wow! sounds like potentially a bad vial to me!

    I hope you get some sleep tonight! Did pushing back the morning basal help with the post breakfast lows?

    Vacations are always hard, because we can't watch things as closely as we would like.

    It sounds like you guys are doing great though.

    Keep up the good work!

    Oh, and I keep the high alarm at 120 almost 24/7 now. If I could drop that to 100 or 110, I would. I need to know when he is trending up before he gets high, or I'll be stuck doing a really big correction!
    Of course I'll have to change that when school comes :(
     
  16. Rachel

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    That is EXACTLY what I do. It just is never the same response ... so after a higher fat meal, I do that and just try to stay ahead of the spike. With the CGM I found I stopped trying to find the magic combo bolus and just go with particular situation as it unfolded. Changing the alarm settings is a big part of that.

    We also try not to have those types of meals too often. I'll be out of luck when Will realizes he can read the kiddy menu at restaurants ... he would likely always pick the mac and cheese (which I swear they must use 2 sticks of butter per serving). I'll order a lighter pasta meal that he and I split ... works well for both of us.

    It sounds like you are off to a great start with the CGM! (Bummer on the set and insulin problems though.)

    Hope the big Sat thunderstorm didn't add too much excitement to your last night at the cabin. :)
     
  17. Jacob'sDad

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    When I went to change the cartridge his BG was trending down fast so I let it play out without changing it. This morning he is right back in range at 113 and was pretty good all night long except where I slightly over corrected an 85 trending slightly down. That got him to 165 which I corrected.

    So the insulin probably was good. I did change the cartridge this morning.
     
  18. betty6333

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    Lol.... FIGURES!!
    I am glad you didn't have to toss the vial. We have only had 1 bottle of apidra go bad before, and it was left in the car for hours when it was 100+ out side.

    Well, I am assuming it went bad b/c we never tried it after that!:p
     

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