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Ketones.

Headache.  Check.  Eyes that weighed at least a pound apiece.  Check.  Mouth full of sweaters.  Check.

Looks like they're all here - the symptoms of a high blood sugar.

Sitting down to catch up on some emails, I absently fish my meter out of my gym back and lance my fingertip.  I hit send, graze against the new infusion set on my left thigh, and see a meter result of 420 mg/dl.

"Oh, that is just fantastic."

Taking out my pump, I calculated the massive correction bolus and felt the quiet sting of the insulin as it coursed through the infusion set I had placed an hour earlier.  Normally when I'm at an elevated blood sugar, I feel lethargic and generally Crumbs Morrone, but this one had a different feel to it entirely.  My stomach felt like it was playing host to a hamster wheel, and my headache was blinding.

I brought the ketone strips into the bathroom and watched uneasily as the pad on the ketone strip turned a deep purple.  Large ketones.  I hadn't seen those suckers since my days at Clara Barton Camp.  I never, ever have ketones, and I test regularly for them.  So where did this come from?

My stomach in knots, I wandered back into the living room and filled Chris in on the situation. 

"I'm high.  Like crazy high - 420  mg/dl.  And I just tested for ketones.  I have large ketones.  I feel like complete shit, and my stomach is really nauseous."

He rubbed my back.  "So what do we do?"

"Drink a ton of water and try to flush out the ketones, I guess.  If I can't keep the water down, we're off to the emergency room."  It dawned on me that I had the process of treating a low blood sugar down to a science, but navigating a serious high was unfamiliar territory.  Normally, I just bolus and wait for the numbers to fall, but this high came with an added bonus of ketones.  The word "ketones" was enough to send me scouring for my old Joslin manuals from 1986, breaking open that red binder and searching for the antidote. 

I drank several bottles of water and willed myself not to throw up, even though my body disagreed with that decision.  "Do not throw up.  Do NOT."  The mantra ran through my head and I tried to relax on the couch, drinking water all the while.  After about an hour, my blood sugar had fallen to 248 mg/dl and the ketones had retreated to "moderate."  Three hours later, my system was flushed clean,Ketones ... huh ... what are they good for? ketones were down to "trace," and my numbers were hovering around 170 mg/dl.

But I was still confused - where is the emergency room threshold?  DKA is defined by Wikipedia as "a life-threatening complication in patients with untreated diabetes mellitus (chronic high blood sugar or hyperglycemia). Near complete deficiency of insulin and elevated levels of certain stress hormones combine to cause DKA."  Okay.  And Joslin had it beaten into my brain that ketones + vomiting = emergency room.  This is serious stuff.  But there is that gray area where large ketones are present and proper management steps are being taken, should I still be under the care of a medical professional?

I opted to stay home and wait it out, since I wasn't throwing up and my blood sugar was falling from that obscene high.  And today, at my doctor's appointment, I asked Dr. Connecticut about when I should be checking myself into the ER due to high blood sugar.  She confirmed that as long as I wasn't throwing up and that my blood sugar was coming down, it was okay to treat at home.  She did add that if I was showing signs of another infection, like a urinary tract infection or a sore throat, that the emergency room should be on my "must see" list.

Over 21 years with this disease and there are still uncertainties that touch in at any given moment. 

Comments

wow, that's crazy. Sorry you had that experience. I haven't had un-expired ketone test strips in my possession since 1988, but bought some this morning after a friend tested positive the other day. Thanks for the refresher course, and I'm glad things improved without you having to go to the ER.

Saw your Twitter updates today and wanted to see what was going on. Soon as I read "ketones." I started to become concerned as well. Sounds like things have turned around a bit. Hang in there, it will get better!

I guess no matter how much experience you have, you learn something new every day.

We typically treat Brendon at home (on the very rare occasion he gets an episode like that).

I guess going to the ER applies when you haven't been diagnosed yet, or don't have insulin on hand????

Based on our experience with Brendon and the ER, we'd have to treat him ourselves anyway. He once had a stomach virus where he couldn't keep anything down, his glucose was too low (hovering in the 40's) and he was coming up to high ketones, but of course we couldn't give him insulin to counteract the ketones.

Anyway, Jeff got him to the ER to get him a glucose drip and wound up doing all the work. The nurses and ER doc let him have at it (they of course hooked the I.V....didn't leave that to Jeff).

That's a great question! I've called my doc paniced over keytones before, and she's seemed unconcerned. I've also thrown up before, but not gone to the ER. My deal with myself is: if I throw up more than once OR if my blood sugar doesn't come down, then I'll go. So far, that deal has treated me well! Glad your blood sugar is better and that the keytones are gone!

I forgot to mention--we had the same blood sugar day. A random 438, sugar, sugar everywhere...

1986 manuals? Hello!!! GOOGLE??? hee hee hee. I'm glad you're okay!

Ketones are the pits. I've only been to the hospital once for persistent ketones with a bad stomach virus. Otherwise we've just done it at home, but ketones don't happen that often for me. I'm glad you're alright now, and I hope it doesn't happen again anytime soon.

Sorry to hear all of that!

My CDE just went over ketones with me last week, resulting in my first supply of Ketostix in I don't know how many years. I was told if I have ketones I should drink water, take my correction bolus by pen/syringe, and swap out the ol' infusion set.

But I guess if your set was new, maybe you'd just want to wait it out and check? Perhaps it started before the new set.

Glad you're better, though. :)

Those times are scary aren't they? When after so long with D we don't know what to do.

I think you followed the right course, water & insulin & testing. Any vomiting and off to the ER you go.

It's only happened to me once, but it was no fun.

It's important to get treated if you're not able to flush the ketones out. As I understand it, they can upset the delicate acidity balance in your body and that becomes a danger to your heart.

Better safe than sorry, and if you're not able to keep plain old water down, get yourself to the ER.

Here's what jumped out at me: "elevated levels of certain stress hormones". Hope you're much better today, and that the nasty highs leave you alone for a while (:-).

I learned all about ketones after spending days in ICU for DKA. I still feel like I have more to learn.

Scary stuff Kerri, I am glad you are okay.


Sorry to hear that u had to deal with ketone's and what they bring. Thank goodness you had the presence of mind to reference the subject and start to treat it.

I was hospitalized twice with ketoacidosis (sp) brought on by the flu in college. My head literally felt as nauseous as my stomach.

Continue to get better, and thanks for the education update.

Kelly K

Hey! Sorry you had that bad episode! I know you felt like complete crap. I am so guilty of not checking for ketones. I don't think I have done that in years. Okay, I am calling my doctor right now to ask for some.

And thanks for the birthday wishes!

The best part of that entire incident was Chris saying "So what do we do?".
You are safe with him. I hope one day Emma has a Chris.

When I was in high school I had ketones and high blood sugar for almost 4 days, but since I never threw up, I never went to the ER. I was changing my infusion sets and taking shots like crazy, but they still stayed elevated. I did call the nurse and talked to her regularly, so you might want to do that next time. When I was sick in college with a fever and ketones - the first time in quite awhile, I gave Gary Scheiner a call. It might be worth adding a nurse or educators phone number to your cell phone for times like these when your 1986 workbooks might just not cut it.

Glad you're feeling better!

I hate that. I have had a random day myself today. Nothing extremely high or extremely low, just up and down and up and down and up and down. It's driving me crazy! I think I am trying to get sick...

Very glad you're OK and glad you could deal with it all yourself. I've never gone to the ER for ketones either, but my first step when I get a headache from a high--even before the purple shows on the strip--is definitely a great big shot from the old-school syringe.

One practical suggestion... when you have lotsa ketones it's important to have a few carbs in addition to the water, even if your blood sugar is high. It doesn't have to be a lot, just a little gatorade or a few crackers to make sure your body has fuel to help turn around the ketone process where your body switches to a different type of metabolism. I also like to have some electrolytes (salts) from gatorade or broth when I'm really high/dehydrated like that, it makes me feel better quicker.

I was right there with you on the ketones... on sunday and monday I basically had ketones the whole 2 days. I had 2 bad sites in a row, so I got really behind. I was away from home, sleeping in a strange bed driving a lot, and unsure if some of that insulin was gonna absorb late and come back and get me, and so I was scared to be really aggressive with insulin corrections.

In the last year, ketone strips have gone from those expired things in the back of my drawer i totally ignored unless i had the flu, to a routine part of my monitoring. haha, i think i am like walgreens' #1 customer for their generic ketone strips. lately i frequently have trace or small ketones from a bad site/bad absorption, that go away as soon as i give a shot and change the site. but this time it was purple - moderate, almost large. and small ketones stuck around for more than 24 hours. i was poking around the unfamiliar kitchen and bathroom at the apt. of the friend i was staying with, up every few hours during the night. worrying about what would happen if i got really sick, away from home, in this apartment with all my sick day tools/foods. and then i was exhausted & late for a really good shadowing opportunity i had the next day.

Thanks for posting about this - it feels good to have company. and i feel a lot less like i am a wimp for whining about this or making a big deal out of it. or for being burned out, tired, lazy, and behind at work & school after those days.

That story hits home for me Kerri. I tried to wait it out one night and I had a blood sugar of about 420-430, and I corrected, but my sugar levels kept raising, and I waited a little longer. And next thing you know the vomiting began and the emergency room was the next stop. I must say though, I didn't wait in a long line at the emergency room.

Kerri..were you using mental telepathy to compare with my son Casey? Same stuff. He woke up ok today, but I feel like crap!

Kerri

That's just lousy.

Did you use a super bolus? For a big high like this it works really well.

I just went through this with my hubby, he refused to go to the ER, even though he did throw up once. His tubing from the infusion set snapped off at the top of the pump and he was apparently without insulin all night (and he ate nachos before bed). It was a fun day, as you can imagine. As we're both T1, he can't fool me into thinking he's OK when he is not. after tons of water, testing and panic on my part, he was OK...it took 8 hours and four times his normal bolus to get him that way. Scary.

Wow. I'm so glad you're okay! This is a good reminder for all of us to refresh our ketone knowledge (mine is seriously lacking, I'm sure).

You say you check for ketones regularly... just when you're high? How high? I never check unless I have a persistent bout of BG over 250... for hours & hours. Wondering if I should be doing this more often?

You can be ketotic without being acidotic. You had ketones, but hadn't had them long enough to go into true DKA (though it doesn't take long on a pump...only as long as it takes the rapid-acting insulin to run out). As the ketones build up, acid accumulates in the blood. As long as you are keeping down fluids and responding to insulin, you can stay home. When you're over 300 on a pump, we tell kids to KISS - check KETONES; INJECT with a syringe; do a SITE change; SELF-MONITOR both BG and ketones. If you are in the habit of doing this, I believe that 90% of DKA is entirely preventable.

Scary stuff. I'm glad that you are ok.

We havne't quite made it to the year mark with Isabelle's diagnosis but about a month and a half ago we were completely surprised with a 500 reading in the early evening. Of course I tested for keytones and they were moderate. I called the endo on call and they just told me to watch her. I was totally prepared for an ER visit. Really scary stuff.

Two weekends ago we spent half a day in the er because of vomiting, dka, 500+ and stubborn. I sometimes wonder if it's a chicken/egg question. Is my daughter vomiting because she's high or is she high because she's vomiting. I've gone to the er even with trace ketones because she feels so much better when hydrated. Stay well, Kerri

The only time I take O to the ER is if she doesn't stop throwing up. She gets dehydrated easily (I've seen her dehydrate, sir. It's pretty gross.) and since being dehydrated also makes you throw up, you really need an IV of saline to counteract that. We haven't had to do it in a long time, but all it usually took was a bag or two of saline.

High blood glucose levels are not fun. Precision Xtra is the only meter that has blood ketone testing ability and it takes 10 secs. What can help.. Keep bouilon cubes. boil water add one, beef or chicken, add ice to cool and drink. The sooner the ketones clear the blood and leave the body the faster the headach goes away. Hope this helps. Having the ability to do blood ketone readings are a great help.

Geez that's scarey. Thank you for reminding me to check my Ketones. I've been having elevated BGs for a week now (two readings in the 400s, most in the 200s) and hadn't thought to check my ketones. I've pulled the bottle out so it's available to me quickly if I go high again.

I LOVE your blog. I can get behind in reading my feeds, but yours is one set to not auto delete.

Give your goofy cat a cuddle from me, please. :-)

Cheers,
Flitterby

I'm coming late here...but Ian NEVER gets ketones either, even when crazy 7 year old sickies hit, and it's good to know that you've gone all this time without as well. I have hope now that he'll probably continue on that path! I apologize that your ketone story was a positive one for me...selfish selfish me.

My sister who was 39 years old died from DKA. She had not yet been diagnosed with diabetes. She had suspected a couple of days before she died that she could have diabetes. The only thing we know is that she went home sick. Where she worked did not call any of our family that she did not show up for work the next day. We did not find her for several days later. The autopsy told us it was DKA, but could not confirm whether it was type 1 or type 2. We have been told that she must have been type 1.

Your comment "It dawned on me that I had the process of treating a low blood sugar down to a science, but navigating a serious high was unfamiliar territory." is so how I feel with my son.

I can handle his lows 99% of the time and get him quickly back up to where he should be. But the extreme highs are not something I'm used to dealing with so it does feel like unfamiliar territory.

Your blogs are enlightning even as a parent of a Type 1, and not being a diabetic myself.

I've had type 1 diabetes for 21 years and I haven't tested for ketones since I was first diagnosed (at age five!). Those random 300 and above bloodsugars always terrify me, though. Maybe I should get some ketone strips.

i have been diabetic for two years and had a few hospital admissions for ketones and high bms if u have high bms and ketones keep giving extra insulin if this dnt help then in to hospital hope this helps

Just had a bad episode today with my 14-yr-old daughter. She RARELY had ketones - once in a great while she might have a small reading. The only time she ever had large ketones for more than an hour was when she had the flu and her blood sugar was pretty low. We just kept her sipping fluids and it cleared up with her flu.

Well, this time, her cannula had slipped out although her set stayed stuck in place and she didn't notice. It was probably out all night and then she didn't get the 2 boluses that she tried to give for the morning and post-2-hr high blood sugars. Didn't check her site until 2 hours after the second correction.

Anyhow, this was the recommendation we've used:

For sugar levels over 250, DO NOT allow carbs. Give a correction dose of insulin at 1.5 to 2 times the normal dose (The higher you are, the more it takes to bring sugar levels down.) and repeat every 3 hours until sugar level is between 200 and 250.

With the first dose of insulin, start alternating 8 ounces of water flavored with boullion cubes (to replenish the body's sodium) and 8 ounces of plain water (or any clear fluids that can stomached) every 20 minutes or so.

Check blood sugar and ketones every 30 minutes.

Once sugar level is between 200 and 250 go back to normal insulin (no more 1.5 to 2) and introduce low-fat carbs (with appropriate insulin coverage for the carbs) to provide the body with necessary energy.

Continue with the fluid pattern until ketones are gone.

If throwing up more than once, cannot keep down fluids, ketones are still moderate to high and not dropping after blood sugars are back to normal (70-120) range or blood sugars do not come down, go to the ER.

For us today, after 4 hours she was finally down to moderate ketones with no nausea and blood sugars in the high 100s (We started at over 600, but don't know since her meter says HI over 600.), and we're still plugging away. She's getting sick of the broth, and just drinking more plain water, but she's at least not nauseated and lethargic and is back to being her own spunky self.

Anyone else try this plan or one similar and have different results? I just can't believe it's taking so long - She must have been pretty bad this time. At any rate, I'm so glad we've got unexpired ketone strips! We went for a long time without.

do you not have a blood check for ketones now?? or are you still on urinalysis testing??

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