Check your infusion site and tubing at least once daily.
If the infusion set tape is peeling loose or if you spot any redness or swelling around the infusion site or blood in the tubing, move and replace the infusion set immediately.
Make sure there are no significant air bubbles in the cartridge before priming the tubing.
If you spot air pockets in the tubing, disconnect and prime until the air has been purged completely out.
And be sure to rotate infusion sites so as not to repeat the same spot twice in a month.
If you smell insulin or detect moisture around any of the tubing joints or at the infusion site, replace the set and tubing immediately.
If insulin tends to seep out at the site when you bolus, extend the bolus delivery time or switch to a longer cannula.
If your pump alerts you of an occlusion, replace your cartridge, tubing, and infusion set immediately.
Change your insulin cartridge as soon as possible after you receive your “low cartridge” warning.
This minimizes the risk that your cartridge will run out completely.
Ketoacidosis: Hypo’s Evil Twin
DKA (diabetic ketoacidosis) is a condition in which the blood becomes highly acidic as a result of dehydration and excessive ketone (acid) production.
In a state of acidity, some of the body’s vital systems stop functioning properly.
It is a serious condition that will make you ill and very uncomfortable, and it can kill you.
Anyone who produces little to no insulin on their own (including just about everyone with type 1 diabetes) is at risk of DKA.
The underlying cause of DKA is a lack of working insulin in the body.
Let me explain.
The primary cause of DKA is a serious lack of insulin in the body.
Normal Fuel Metabolism
Most of the body’s cells burn sugar (glucose) as a primary energy source. Many cells also burn fat but in much smaller amounts. Glucose happens to be a very clean form of energy, there are virtually no waste products left over when cells burn it for energy. Fat, however, is a “dirty” source of energy. When fat is burned, the cells produce waste products, which are called
ketones . Ketones are acid molecules that can pollute the bloodstream and affect the body’s delicate pH balance if produced in large quantities. Luckily, we don’t tend to burn huge amounts of fat at one time, and the ketones that are produced can be broken down during the process of glucose metabolism; glucose and ketones can “jump into the fire” together. (See Figure 9.4 .)
Figure 9.4: Normal fuel metabolism
Obviously, having an ample supply of glucose
inside the body’s cells is important. That requires two things: sugar (glucose) in the bloodstream and insulin to shuttle the sugar into the cells.
Abnormal Fuel Metabolism
What would happen if you had no insulin?
I’m not talking about a minor underdosage; I’m talking about having none whatsoever.
A number of things would start to go wrong.
Without insulin, glucose couldn’t get into the body’s cells.
As a result, the cells would begin to burn large amounts of fat for energy.
This would lead to the production of large amounts of ketones.
Although some of the ketones would eventually spill over into the urine, the body would be unable to eliminate sufficient amounts to restore a healthy pH balance in the bloodstream. (See Figure 9.5 .)
Figure 9.5: Fuel metabolism in the absence of insulin
Dehydration further complicates the problem. Without sufficient insulin to inhibit the liver’s secretion of sugar, large amounts of glucose would be released into the bloodstream. Because high blood sugar causes excessive urination, dehydration would ensue. Without glucose metabolism to help break down the ketones and without ample fluids to help neutralize the ketones, the bloodstream and tissues of the body would become very acidic. This is a state of ketoacidosis.
Causes and Prevention of Ketoacidosis
What can cause a sudden lack of insulin in the body? There are a number of potential culprits, several of which were described above:
• using spoiled insulin
• missed injections, or gaps in basal insulin delivery
• failure of insulin to absorb once it is injected or infused
• insulin pump (or infusion site) malfunction
• improper use of SGLT-2 inhibitors
A lack of insulin is not the only thing that can cause production of ketones and, potentially, DKA. Illness, infection, dehydration, and major stress can cause the production of large quantities of stress hormones, which counteract insulin. In other words, you could have insulin in your body, but it is rendered almost useless because stress hormones are blocking its action.
A lack of carbohydrates in the diet can also induce ketone production.
During periods of starvation, prolonged fasting, or severely restricted carbohydrate intake, the body’s cells must resort to burning alternative sources of fuel, namely fat.
With increased fat metabolism and limited glucose metabolism, ketone production may exceed the body’s ability to eliminate them.
Nutritional ketosis is different from diabetic ketoacidosis in that the ketone level does not become dangerously high, dehydration should not occur, and the pH of the body’s fluids remains close to normal.
However, nutritional ketosis has its drawbacks, particularly for the first couple of weeks after starting a ketogenic diet.
These include headaches, mild nausea, and a general lack of energy (what many describe as no “get up and go”).
Maintaining at least a modest level of carbohydrate intake throughout the day should prevent ketosis.
If you must fast for short periods of time, talk with your doctor to ensure that it will not interfere with any other health conditions or medications that you may be taking.
You can usually fast safely by taking only basal insulin, with rapid-acting insulin as touch-ups for high blood sugars.
If you take intermediate-acting insulin (NPH) in the morning, take half of your usual dose.
Be sure to check your blood sugar level regularly during a fast.
If your blood sugar drops below 70 (3.9), you must eat carbohydrates to bring the blood sugar back up.
Use of SGLT-2 inhibitors can also induce DKA in people with type 1 diabetes.
This is due to the way SGLT-2 inhibitors work: they cause loss of glucose through the urine, which produces extra urination and a reduction in insulin requirements.
Those who become dehydrated, consume insufficient carbohydrates, and reduce their insulin doses too much put themselves at risk of DKA.
However, this risk can be virtually eliminated by consuming ample carbs, drinking plenty of water, and making sure insulin doses are not missed or decreased any more than is necessary to maintain healthy blood sugar levels.
It is also beneficial to monitor ketone levels routinely (preferably with a blood meter that measures ketones) and report any elevations to your prescribing physician.
The first and most important step in preventing ketoacidosis is early detection of a problem.
This starts with frequent glucose monitoring (via CGM or fingersticks), followed by ketone checks with unusually high blood sugar levels.
The absence of ketones indicates that the high reading is probably due to insufficient insulin coverage for food eaten recently.
The presence of ketones indicates either severe insulin resistance (caused by illness, infection, or stress) or a severe lack of insulin in the body (caused by spoiled insulin, missed doses, malabsorption, or a pump malfunction).
Assuming you’re not unusually stressed or ill, the troubleshooting process is shown in Figure 9.6 .
Figure 9.6: A simple process for early detection and prevention of DKA
Three steps should reverse the problem if ketones are present.
1. Give an injection of rapid-acting insulin from a fresh vial, based on your usual correction dose. Injecting into muscle will help bring your blood sugar down faster and ensure that it absorbs completely.