High BG and large keytones. How much insulin to take by injection?

This morning I was awaken early to find a surprisingly high (300s!) blood sugar... I tested ketones and they were also present in large amounts. (The long story is here).

When I started on the pump, the CDE who trained me told me to take six units of insulin by syringe, then to monitor my BG going forward and correct as necessary, just keeping in mind that those 6 units wouldn't show up as "on-board" by the pump. It seemed arbitrary and not based on any actual measurements, but it's easy to remember.

Since moving and switching doctors, I've been given different advice: to calculate the correction based on my BG at the time, then to do some other mathematical calculation (I forget what it is) to determine how much insulin to take. It made sense, but was far too confusing to remember, and too hard to calculate in my head, especially in the middle of the night with my head spinning.

Obviously, since I can't remember the second bit of advice, I took the first. But what is the RIGHT thing to do? Is there a right thing, since there's no way to really know how long the basal was knocked out for? Is the right thing (keeping a scientific calculator at my bedside) really practical?

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Every time I watch the phlebotomist draw my blood, I wish that I could uneventfully execute that move to bring down high BGs super fast.

I wonder if we diabetics could be taught that skill?

What I know, for myself, from practical experience is that my ISF with a pump is much different tham my ISF with MDI. I'm not sure what's to be gained by injecting into muscle, but I'd have to inject twice as much as the calculations specifiy using MDI to bring my BG down from the 300s, so I just correct using my pump now.

I suck it up and hope for the best. In your circumstance, I would have been awake in an hour or so anyway so I'd do what I could to monitor the situation. At that point, whether it was back into normal range in one, two, or three hours would not have made much of a difference as long as it came back down.

FHS - It's been so long since I used MDI, I don't remember using a very different ISF number for MDI vs. the pump. I haven't used MDI since 1987. I don't doubt your experience.

The only thing that worries me about using the pump to deliver a correction for BGs > 300 is that the super high BG may be the symptom of a pump/site failure. At that point I need to initiate a positive counteraction with a high degree of confidence. Giving a correction that fails to do its work greatly increases the risk of DKA. That's a chance I'd prefer not to take.

Yeah, that's definitely a possibility worth considering and definitely a reason to bolus wit ha syringe.

Luckily, I've rarely been over 300 in the last 2 years. In fact, the only times I have been over 300 are situations where I had to bolus with a syringe instead of my pump to cover a meal. I just wayyyyyy underdosed because of the different ISFs.

Other times where I have been close have been a mix of underdosing and bad sites. Either way, I figure the best way to find out if it is my site is by bolusing with my pump. I'll burn strips hourly, or even every 30 minutes to monitor the situation.

That's exactly what the ketone test is there to determine. If ketones are present, then basal insulin wasn't getting into my system and the pump site is no good. I could change the site and then pump the correction, but I feel it would work faster by syringe if I could find the muscle. And even if I can't, it takes time to prep a new site (fill reservoir without bubbles, insert infusion set, etc), and I wanted to remedy the situation as soon as possible.

If ketones were not present, or I could explain the high BG with poor eating or a missed bolus or something, then I'd go ahead and correct with the pump.

Sounds like everything worked out for you so it lookes like you did the right thing.

That's a point that I had not considered before. If ketones are present then the site is bad and it's most likely bad because of the interruption/reduction of basal insulin. DKA does need some time to develop and a high blood sugar excursion after a meal does not trigger ketones if normal glucose is restored in a few hours.

I need to get some replacement blood ketone strips for the meter I got last year.

A bit off-topic, but do you use the Novamax blood ketone strips? I just use the urine ones -- and they're way over a year old. But I basically use it for a "yes" or "no", the value isn't all that important. (Unlike the transition from urine glucose to blood glucose tests, which was VERY important!).

Do you find them to be better?

Yes, I do use the Nova-Max ketone strips. I received a free kit with two ketone strips which I've used up. I also had another blood ketone system that I've used in the past. I rarely need to test for ketones and I haven't tested above the published threshold. I think it's a good thing to have on hand, however, and I need to get a prescription for more strips.

Sorry, I can't give you a comparison to the urine strips as I've only used those a few times early in my diabetic life and the event was unremarkable. Perhaps your "yes or no" value is all you need. I do think it's easier to prick a finger for a blood sample than it is testing urine.

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