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Please carry glucagon, you never know...

Discussion in 'Parents of Children with Type 1' started by missmakaliasmomma, May 9, 2014.

  1. mmgirls

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    shouldn't the bolus have been less than 3.5 if she was below target (120)?

    What is her ISF?

    I do not think that 120 is a "too aggressive target", but if you are not buffering it a few carbs or reverse correcting down to it then maybe that is too aggressive for a young child that is hypo-unaware that may not have a 1:1 assistance next year.
     
  2. wilf

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    We know from OP's previous posts that her daughter was in line for ice cream when she collapsed. Presumably she wouldn't line up for the ice cream until after she had eaten. Lunch starts at 11 am, so lets say she'd gotten done in 15 minutes and then lined up..

    We also know:
    - No breakfast bolus.
    - Lunch prebolus given 10:40 am (from the pump).
    - She was 31 at "like 11:19 am", so about 40 minutes later. It would be good to know the precise meter time as there is maybe some confusion on that point.
    - BG of 96 when she was given insulin.
    - Bolus of 3.5 units.
    - She weighs 38 pounds or 17.3 kg.

    Ok, here's some analysis.

    1) If she is getting a TDD of 17 units a day (which would be a lot - 1 IU/kg/day is huge for a girl that age), then using the 1800 Rule she has a Correction Factor of about 100 (ie. a 1 unit correction should drop her about 100). If her TDD is less (which I suspect), then the Correction Factor is higher (ie. one unit would drop her even more)

    2) She got 3.5 units, prebolused. The bolus was upped to cover the ice cream. Problem is there was a line for ice cream, and all of the prebolus which was meant to cover the ice cream was acting as a correction.

    3) If we assume that 1.5 units of the prebolus were intended to cover the ice cream, then she had a "correction" of 1.5 units going - enough to drop her say 30-60 points over the time that the insulin was working after the prebolus.

    4) 40 minutes after the prebolus (when she collapsed) was certainly enough time for her to go dangerously low, given the starting blood sugar of 96.

    The questions I would still have are:
    - What's her TDD? (having a better fix on that allows a better calculation of Correction Factor)
    - Exactly when was the 31 measured?
    - Did she have gym or exercise in the morning?
    - Should there have been a "negative correction" given she was below target at the time of the prebolus?

    The main question I would have for the nurse would be why (given that there was a honking big prebolus going) did the nurse not ensure she got the bolused ice cream more quickly - by talking with staff and moving her to the front of the line?

    It's good she gave the glucagon, but when we prebolus we need to be very clear that the "clock is ticking" - and for as long as any carbs bolused for have not been eaten, the insulin dedicated to those carbs is acting as a correction..

    Thanks again to OP for this thread. Lots of good learning to be had here. :cwds:
     
  3. coni

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    The nurse was mistaken or lied about the 11 BG, so I wasn't sure if she misrepresented other facts. I'm sure your version is correct if the child ate lunch.

    I agree that the OP has given us valuable food for thought.
     
  4. Melissata

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    If she were 96 but headed down, then a 20 minute pre bolus would be enough to send her very low in this case. I would suggest only a 5 minute pre bolus from now on at school. This incident could help you to get approval for a Dexcom, so be sure to document it.
     
  5. rgcainmd

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    My daughter and the 2 other kids with T1D at her middle school always go to the front of the lunch line (or snack or treat line); it's pretty much a rule. The entire school has been educated as to why and no one bothers or teases my daughter and the 2 boys with T1D. The OP's daughter should have been granted this accommodation.
     
  6. caspi

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    This is what I was thinking as well. If she did just eat and then glucagon was administered, I am really surprised she didn't vomit.

    Yes. This.
     
  7. wilf

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    It should be pretty easy to establish that she ate - she was in a cafeteria, with lots of people around.
     
  8. caspi

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    I would hope so. I know when my son was in elementary school there was a lunch aide that would keep an eye on him to make sure he was eating. Given the confusion in this instance with the nurse, it's hard to know for sure.
     
  9. missmakaliasmomma

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    It would have reverse corrected, I mean, that's what it does so it should've....

    Tdd varies a lot. Avg is probably around 14.
    31 was I BELIEVE 11:19
    No gym
    I'm assuming it did a neg. correction

    Lol yes, plus my dd is a pig
    No, just that week

    Thank you, and no record at 11am


    I don't know how to calculate what her correction factor should be, is that what you are all talking about with 1800 & 500 rules?
     
  10. Megnyc

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    Ok, I have two theories.

    Theory A (most probable in my opinion)

    10:40- BG is 96 and bolus 3.5 units
    11:00- She goes to lunch and for whatever reason doesn't eat anything.
    11:18- 40 minutes post 3.5 unit bolus (lets say .75 unit had worked by then and dropped her down to 30 since no food has yet to be consumed). She collapses
    11:19- nurse gets BG of 31 but in her panic sees 11. Nurse gives glucagon. The pain of the IM injection is enough to get her to respond (unlikely but let's go with it).
    11:40 (estimated time)- BG is 361

    For whatever reason the nurse is either mistaken about the time frame or lying about when the actual fainting/glucagon admin occurred).

    Theory B
    10:40- BG is 96 and bolus 3.5 units
    11:00- She goes to lunch and trips on the ice cream line and hurts her knee. Faints from pain.
    11:01- nurse gives glucagon. She responds immediately because she was never low to begin with.
    11:19- nurse realizes she gave glucagon for no reason and panics so she uses control solution or dilute blood to get the 31.
    11:40 (estimated time)- BG 361

    This makes sense but it doesn't seem likely to me that the nurse would go to that much trouble to get a low number in the meter. It still doesn't explain why the nurse is claiming a BG was done at 11.


    Nurses proposed timeline
    10:40- BG is 96 and bolus 3.5 units
    11:00- She faints on lunch line
    11:01- Nurse gets BG of 11 or LO (impossible since it was not in meter)nurse gives glucagon. She responds immediately (again not possible to respond immediately to glucagon).
    11:19- BG is 31. (Basically impossible since 20 minutes post glucagon assuming decent glycogen stores [which we know are there by the later 361] BG is going to have risen at the very minimum 50+ mg/dl)
    11:40 (estimated time)- BG 361
     
  11. wilf

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    The 1800 Rule is based on empirical observations and can be used to make quick, rough calculations of Correction Factors (aka insulin sensitivity factors, or ISFs) as follows:
    Correction Factor = 1800 / TDD

    In my daughter's case she gets about 30 units a day, so 1800/30=60. According to the 1800 Rule, 1 unit of insulin drops her blood sugars by about 60 mg/dL. And in fact, that is what I use when making corrections - it works well for her.

    In your daughter's case she gets about 14 units a day, so 1800/14=128. According to the 1800 Rule, 1 unit of insulin drops her blood sugars by about 128 mg/dL. How does that match up with the ISF from your endo?

    Anyway - if as I guessed the ice cream part of her bolus was being covered by 1.5 units, then by the time she collapsed this overdose could have dropped her by about 40 to 80 units (assuming an ISF of 128).
     
  12. Megnyc

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    Wilf, do you really think any amount of novalog could result in a drop down to 30 or so from 90 in 20
    Minutes? I'm under the impression that the bolus was given at 10:40
    And then fainting happened at 11. I just can't see novalog working that quickly even if she was on her way down already.
     
  13. coni

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    I know you said your daughter ate. I hope you know this for a fact and it's not based on what the nurse said.

    I totally understand what Wilf is saying and think it's a logical explanation.

    The problem I have is if lunch is at 11:00 and the "after glucagon" BG is at 11:19, that left 19 minutes to eat, stand in an ice cream line, fall down, have the nurse notice and pick up the child, administer glucagon and take a BG.
     
  14. caspi

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    Did you actually speak to someone (other than the nurse) that saw her eat her entire meal? The fact that there is no record of anything at 11 is just a huge red flag to me.
     
  15. missmakaliasmomma

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    No, however my daughter is a serious pig. Like, unnaturally so. Is everyone so sure on here that a "lo" would in fact store in the Aviva meter? I want to make sure I'm not jumping to any conclusions.


    Isf at school is 120. However, it is higher all other times. I know that at one point it's 165 and I believe 200 at night.



    I changed her basal a little today and she was 167 before snack so I'd say the I:c is correct. With no prebolus, she only spiked to the 230 range so I was happy with that.
     
  16. missmakaliasmomma

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    Btw, I will ask the dr about the "lo" reading that should be in the meter from what I'm gathering here.
     
  17. Megnyc

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    I'm totally sure. I even scrolled back in an old aviva meter I had lying around and found a lo in there.
     
  18. missmakaliasmomma

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    Now I'm concerned. Not so much about glucagon given since she was 31, but the fact that I was lied to.

    I never mentioned that we just so happen to have a 504 meeting to determine if she needs her nurse for next yr. it's possible that with a documented low bg that resulted in glucagon, her job would be solidified for another yr
     
  19. wilf

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    Read the OPs posts more carefully. It was 39 minutes from prebolus 96 to meter reading of 31 (after she had collapsed). My guess is she got the glucagon when she was measured at 31. It's the simplest hypothesis, and the one that makes the most sense to me..
     
  20. rgcainmd

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    This makes me seriously ill to think that someone would resort to something as despicable as causing a low BG to save her job. But it is certainly beginning to look like this may have been a big motivating factor. How creepy is that: cause a child to have a dangerously low BG in order to necessitate emergency treatment that will justify the need to continue getting paid for looking after a child whose life you endangered...
     

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