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Help me understand

Discussion in 'Parents of Children with Type 1' started by Lakeman, Apr 30, 2015.

  1. Lakeman

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    We are new to pumping and are having a problem tonight that I hope you all can help me understand.

    Went out to dinner (high fat meal) around 6 then to karate (went low and treated at 7:30). Dexcom graph shows a clear rise starting right when we treated the low. But rather than stopping the rise continued right up until the Dex only read "High". We could not correct early because there was insulin on board from dinner but we did correct around 8:30 then again at 9. The pump would not let us do a very large correction do to IOB at these times. According to the graph on the Dex the corrections had no effect. At 10:00 when she was 385 on the meter I did another correction. She came down to 350 over the course of the next hour but then started to go up again. Checked BG on the meter (350) and checked for ketones which were .2.

    At this point I looked at the tubing and it was not an even color all the way along its length. It did not quite look like air bubbles in the tube but I am thinking that is the most likely reason for the discoloration. The pump was delivering the correction at this time and I did not see any movement of what I suppose were air bubbles.

    So my questions are: do you think these are air bubbles? Can I disconnect the tube and purge the bubbles if that is what they are. She has about 36 units left in the pump, does that make a difference? She ran a 5k run earlier today, could that cause air bubbles? Would air bubbles cause less insulin to be delivered (causing a high) but still allow some to be delivered (causing not too much ketones and some reduction of a high)?
     
  2. Lakeman

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  3. suej

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    Hi Alan, what pump does your daughter have? My son has medtronic and uses quicksets and sometimes swings the pump around on the tubing (against my advice) which results in greyish opaque segments as the plastic tubing is put under stress. However, this has never affected insulin delivery or caused highs. It definitely does not look like air bubbles, but I could not open the second link to see if it looked like that - sorry. Air bubbles should move with insulin delivery, and they could definitely result in less insulin than expected being delivered. And if they are air bubbles one can definitely disconnect and purge. I do not think a run would cause air bubbles (my son plays all sorts of sport with pump, including cross country and he has not yet had an air bubble problem.

    I wonder if your daughters low then sustained high was due to delayed absorption of the carbs in due to high fat meal that then showed up later as a "fat high" which I have always found stubborn to treat and requiring bigger doses than usual. We actually do not use the bolus wizard function and correct as soon as he goes high. If I think there is a "fat high" I bolus about 150% of usual correction dose, then there is usually at least an hour before Ben's sugars start to drift down. If they are not coming down after about an 90mins I do do another correction. Sometimes also put on increased temporary basal - Think like a pancreas has guidelines as YDMV.
    Hope you come right
    Kind regards
     
  4. Sarah Maddie's Mom

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    I think those image accurately reflect air bubbles and tubing discoloration. Most likely it was the restaurant food that caused the high. Did you extend the bolus? If not, give that a try next time and see if that doesn't help. It's one of the best things about pumping so don't be afraid to put it to work.
     
  5. hawkeyegirl

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    What you describe is almost a textbook example of a fat spike. I'd be fairly confident in saying that's what happened.

    Next time, dose her for part of the meal up front and then extend the rest of the dose over 3 hours. It won't be perfect, but it's a good starting point. And you can override the pump's calculations and give a correction within the DIA. We do it at least once a day. Once you see that fat spike hit, existing IOB will never, ever, ever be enough to bring that high down.

    ETA: When Jack was little, maaaaaaaybe we had a couple of air bubble issues, but now that he's older, some small air bubbles here and there wouldn't really have that big of an effect on anything.
     
  6. virgo39

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    We find that once BG is over a certain level, especially at night, a standard correction usually is not enough. This seems to true regardless of whether there is IOB. We almost automatically increase basals by 50% or 95% for at least two hours in combination with a correction. We are also more comfortable overriding the pump recommendation.
     
  7. shannong

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    I would agree with the others that said that the high blood sugars were the result of the restaurant meal. However, in regards to the air bubbles question, bubbles in the cartridge do affect my son greatly. In fact, a big part of achieving good blood control for my son has been to make sure that there are no air bubbles. My son's TDD is only about 20 to 25 units, so perhaps bubbles affect him more, I don't know. When I am trouble shooting high blood sugars, I will often rewind and take the cartridge out and look for bubbles that get caught in the connector part of the tubing - this is actually where I find we run into problems. I'm not sure why, but they don't necessarily end up in the line, but rather in the connector and it seems to affect delivery. If I suspect something is wonky, this is often the reason for us (that or a bent cannula).
     
  8. KHS22

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    I'd guess the highs were from the high fat meal. If you read up on newer studies on fat, up to 8 hours after high fat meal the BG rises. Some folks use Fat Protein Units (we do) to help deal with this. And for high fat meals, it is often about double the insulin you would use for just carbs. Which, you probably gave in corrections!

    I'm sure others can 2nd that high fat meals can make their kids skyrocket for hours!
     
  9. jenm999

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    Ooh! Tell me about fat protein units, and how you count/dose for them. Thanks!
     
  10. Lakeman

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    I would like to thank everyone who responded to the thread. As usual hindsight is always best and now that it is the next day we do know what happened. We changed her sight on schedule the next morning and once the tubing was off I was able to look at it closely - not air bubbles. Secondly, once I noticed that the highs were not coming down I did a correction with a syringe and it worked beautifully. Conclusion: bad insulin. I had previously considered bad insulin briefly but set that thought aside because it had not been hot enough. Nevertheless, insulin from a syringe worked great and the tubing was fine.
     
  11. hawkeyegirl

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    I think it's unlikely that the insulin went bad just as she was eating a high fat meal. The reason the correction worked with the syringe is that her body had metabolized the fatty food by that point and was no longer insulin-resistant. That is typical of a fat spike as well. Correction 1 doesn't work. Correction 2 doesn't work. Correction 3 doesn't work. Correction 4 - zoom, down goes BG.
     
  12. Melissata

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    Absolutely agree with this. In all of the years we have been dealing with two type 1's, never have had bad insulin. It was either a bad site or the fat, and I am betting on the fat.
     

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