2. Inject enough lispro at these times to bring your blood sugars down to yourtarget value. Intramuscular shots arepreferred (see
350 Treatment
pages 307-310) because of their rapid effect, but subcutaneous injection isalso acceptable. It isprudentto continue bloodsugar measurementsand insulincoverage, evenduring the night, for as long as blood sugarscontinue to rise. If you're so illthat youcannotcheck yourownblood sugars and in ject your own insulin, someone else must do this for you, or you shouldbe hospitalized. The potential consequences are so seriousthat you haveno other options.
Medications to Be Discontinued Certain medications that can accelerate dehydration or temporarily impairkidney function should be discontinued during a dehydrating illness.
These include diuretics, ACE inhibitors, and certain arthritis medications such as NSAIDs (ibuprofen, Motrin, Advil) and COX-2 inhibitors.NSAIDs may, however, be usedas a last resort to treat fever if other medications are ineffective.
Discuss this with your physician beforediscontinuing medication he has prescribed.
If you can't reach him, then discontinue.
Controlling the Vomiting The mainstay of treatment is fluid replacement, but if you've been vomiting, you'll probably be unable to hold anything down,including fluids.
If symptoms disappear aftervomiting once and you can keep things down, then there's likely no needfor treatmentto prevent fur ther vomiting {butstill notify your physician).
Ordinary vomiting can usually besuppressed withTigan (trimethobenzamide hydrochloride) suppositories, administered rectally every 3-5 hours if vomiting per sists.
Tigan should not be taken bymouth,asit will probably be vom ited up before it can work.
Suppositories should be stored in your refrigerator, as they tend to melt in hot weather.
The suppository should be inserted well into the rectum, blunt endfirst, so it won't come out.
Tigan works for most people, but in about a third of cases, it doesn't, which is all the more reason to contact your physician when youexperience a potentially dehydrating illness (nausea, vomiting, di arrhea, fever).
If vomitingor nauseacontinuesfor more than 4 hours, or if it cannot be halted by Tigan within 1 hour, he or she may want you to try a second or even a third dose or may prescribe a visit to a hospital emergency room to receive intravenous fluid (saline) and to
How toCope withDehydration, Dehydrating Illness, andInfection 351
have the cause established.
Some surgical emergencies such as intesti nal obstruction can lead to vomiting, as can poisoning, gastroparesis (Chapter 22), DKA, and so on.
Vomiting is a serious problem for people withdiabetes, and should not betreated casually.
Large doses of Tigan cancause bizarre neurological side effects, es pecially in children and in slim elderly people.
When vomiting has ceased, itshould probably notbeadministered more often than every 3 hours, or in doses greater than that prescribed by your physician.
I usually recommend 100 mg suppositories for children and slim people olderthan 65years, and 200 mgsuppositories for all others.
If Tigan doesn't work fully within 1hour, take more andcall your physi cian again.
Fluid Replacement Once vomiting has been controlled, you should immediately begin to drink fluids.
Two questions naturally arise at this point: What fluid?
And how much?
There are three factors that must be considered in preparing the fluid to be used.
First, it mustbepalatable.
Second, it should contain no carbohydrate (therefore noGatoradeor other sportsdrinks),but artificial sweeteners areokay.
Thisguideline alsocontradicts conventional treatment, which usually calls for sweetened beverages to offset the excessive amountsof insulin that many diabetics use.
Finally, the fluids should replace the electrolytes , sodium, potassium, and chloride , that are lost from thebody when we lose fluids.
Beverages commonly used bymypatients include diet soda, diluted iced tea, seltzer, water, and carbohydrate- free bouillon or clear soup.
To these fluids, weadd electrolytes.
To each quart of liquid, add: Exactly but no more than 1 level teaspoon table salt (Vi tea spoon if it tastestoo salty) (provides sodium and chloride) Exactly but no more than V4 teaspoon salt substitute (see list, page 67) (provides potassium and chloride)
Ifthevomiting ceased after oneepisode without the need forTigan, it isn't necessary to add the salts to the fluid youconsume. In anticipation of these rare "sick days," you should always have on hand several 2-quart bottles of dietsoda or seltzer, or two empty 2-quart plastic iced tea pitchers. The pitchers can be used to store whatever rehydration concoction youmayprefer instead of diet soda.
352 Treatment
When the needarises, one pitcher of fluid can be keptby yourbedside, whilethe second is kept coolin the refrigerator.
The volume of fluid youwill require each day, whennot eating, de pends upon your size, since large people utilize more fluid than small people.
Ifyour blood sugars are elevated orif your urine ondipstick is positive for more than moderate amounts of ketones, you will need much more fluid than otherwise.
The ongoing fluid requirement for most adults without these problems comes to about2-3 quarts daily while fasting.* In addition, within the first 24 hours you should re place the estimated fluid loss caused by vomiting, fever, or diarrhea.
This maycome to another few quarts, so clearly youwill have to do a lot of drinking.
Your physician should be consulted for instructions regarding your fluid intake while ill.
If for anyreason you cannot con sume orkeep down theamount of liquid that she orhe recommends, you may have to behospitalized to receive intravenous fluids.
If you do have to behospitalized for IV fluid replacement, you may run into the difficultyof inexperienced or ignoranthospitalpersonnel wanting to give you one or another standard solution that contains some sort of sugar , glucose, lactose, lactated Ringer's solution, fruc tose, and so on.
Do not allowthem to do so, and do not assume they know more than you do aboutyour situation.
Insist upon a saline so lution,1 and if they balk, insist upon speaking with the hospital ad ministrator and threaten malpractice and wrongful death lawsuits, if necessary, to persuade them of what you need.
Although not usually effective outside the United States, such threats are usually effective here because malpractice insurance companies will likely insist upon the discharge of the person who precipitates a lawsuit.
Diarrhea Here again we are faced with three basic problems: blood sugar con trol, control of the diarrhea to prevent further water and electrolyte loss, and fluid and electrolyte replacement. The guidelines for blood sugar control are the same as if you have
Figure on 0.02 quarts per pound of body weight (0.044 liters per kilogram). Thus,about 3 quarts (or 3 liters) for a person weighing 150 pounds (68kilos), beware of D-5 or D-10 saline solutions. These contain dextrose (glucose) and will certainly raise yourblood sugar and thereby cause furtherdehydration. For uncontrollable diarrhea, halfnormal saline should be used; otherwise, normal saline.
How to Cope withDehydration, Dehydrating Illness, andInfection 353
been vomiting (see above).
Fluid and electrolyte replacement should be the same as for vomiting, except that 1 level teaspoon of sodium bicarbonate (baking soda) should be added to each quart of the electrolyte-replacement mixture.
The primary treatment for diarrhea, as for vomiting, is to stop eating.
Medications to relieve diarrhea, if any, should be specified by your physician.
Some forms of diarrhea caused by bacteria, such as "traveler's diarrhea," maywarrant the use of Pepto-Bismol (bismuth subsalicylate) and antibiotics such as cipro floxacin.
In my experience, there is one antidiarrheal agent that has always worked, Lomotil (diphenoxylate Hcl with atropine sulfate).
This is a prescription drug thatyou should have your doctor prescribe inliquid form in a dropper bottle (in advance of any illness).
The generic ver sions are much less expensive and just as effective.
You should always have several bottles on hand.
You will find dosing instructions on the package insert.
If diarrhea continues, double thedose every hour un tilit ceases and continue the final dose every 3hours until your physi cianadvises you to discontinue. (Once the diarrhea ceases, it would be moreconvenient andcheaper for an adult to switch from the liquid to the tablet form of the drug.
One 2.5 mg tablet is equivalent to 1 tea spoon or full dropper of theliquid.) Overdosing will not onlydryout your gut, which we are seeking, but can dry out your larynx, mouth, nose, andeyes.
Lomotil can also make youdrowsy, but itseffect on di arrhea is miraculous, in my opinion.
FEVER
No doubt you've heard the advice, "Drink plentyof fluids," for a fever.
This isbecause fever causes considerable fluid loss through theskin as perspiration.
Your loss of fluid can be difficult to estimate, so your physician maywantto assume that you'd require 1-2 more quarts of fluid daily than you'd normally need.
Ordinarily, amildfever helps to destroy the infectious agent (virus or bacteria) that caused the fever.
The tendencyto sleep out fever may also be beneficial.
For a diabetic, however, the somnolence that you experience with fever maydiscour age you from checking yourbloodsugar, covering with insulin, drink ingadequate fluid, and calling your physician every few hours.
If you don't have someone awaken youevery 20minutes, you should useas pirin, acetaminophen (Tylenol), or ibuprofen (Advil or Motrin), in
354 Treatment
accordance withyourdoctor's instructions, to helpfight the fever.
Be ware, however, that aspirin can cause false positive readings on tests for urinary ketones, sodon'teven test for ketones if you are using as pirin.
Never use aspirin or ibuprofen (or any ofthe nonsteroidal anti inflammatory drugs, NSAIDs) for fever in children because of the risk of Reye's syndrome.
Excessive doses of aspirin or NSAIDs (naproxen, ibuprofen, and many others) can cause severe hypoglycemia.
If at all possible, try not to use NSAIDs, as the combination of these drugs with dehydration can cause kidney failure.
Acetaminophen can be highly toxic if used in doses greater than those indicated on the pack agelabel.
If you have fever, the guidelines for blood sugar control and re placement of fluid are almost the same as indicated previously for vomiting.
There is one difference, however.
Since there is very little electrolyte loss in perspiration, it's not necessary to add salts to the fluid you consume if you're not vomiting or experiencing diarrhea.
Certainly there isnoreason notto eat ifyou feel hungry, but if you wantto eat,cover yourmeals withyourusual dose of insulin or ISA.
If you're hungry for only asmall meal, eat halfora quarter ofyour usual protein andcarbohydrate, and cover it with only halfor a quarter of your usual dose of insulin or ISA.