Not a friendly HI as in HELLO - a dreaded HI*!
We never, ever had that reading before. At diagnosis, his BG was 27 and the glucose meter did measure 27 / 28 (on One Touch meter) on two other occasions shortly after diagnosis, but never HI. Not even when he was accidentally disconnected from the pump overnight.
What could have caused it, we wondered?
Instantly, both my husband and I went into “trouble shooting mode” and started showering Mr. T with questions. That is what you do when you are a D parent - you want to avoid such a thing happening again so you want to get to the bottom of it and learn from it.
- Did you test at morning tea? - YES, it was 9.9
- Did you correct then? - YES
- Did you eat anything for morning tea? - NO
- NO? Are you sure? How can it be that it is so high if you did not eat anything? Are you sure?
I took time to explain that we are not angry with him for being HI, it happens, we just need to understand what has caused it so we can fix it properly and then teach him how to avoid it in future.
Together, we analysed the day again by going through the pump “history":
I saw a bolus (insulin dose) of 2.90 at 8:30am ! ( we dropped him at school at 7:30)
That is not at morning tea time (10:15am), that was just half an hour after school had started.
Mr. T then remembered that they were all helping with setting up for a Swimming Gala and serving some food. He had a mini-pie and he had bolussed for it ! FANTASTIC that he had remembered to bolus, BUT 2.90 units of insulin sounds TOO MUCH for a mini-pie. He had guessed the carbs to be 35g (mini pies are usually around 11g of carbs, needing less then 1 unit of insulin in Mr. T’s case). HUGE difference. He simply made a mistake in carb counting. That happens to more experienced carb-counters and of course it will happened to Mr. T many more times to come.
There were no other entries in the pump, but the meter showed a BG of 13.3 at 10:10.
So I reconstructed the morning events: too much insulin (three times the actual required dose) at 8:30, pulled him down and possibly resulted in a LOW at about 9:30 (insulin peaks after an hour).
LOW has activated the release of his own glucagone which instructed the liver to dump glucose in to his blood stream protecting him from losing consciousness. Thank God for that, otherwise he would have probably fainted. Now, the problem is that there is no incoming insulin to stop and counteract that glucose dump (healthy pancreas in non diabetics would secrete the needed insulin and the BG would remain in range), so the BG keeps on rising and rising and staying high for hours to come.
And thats’ what they call a rebound - a HI after a LOW caused by the liver dumping glucose.
That is why, two and a half hours later, after the first correction dose and despite the increased basal of 100% for 2 hours - his BG was still 25 ! Yes, that’s how stubborn liver dumping glucose is (it is a very individual thing though). All you can do, if this happens, is to keep checking the BG frequently and keep correcting.
I made this time line of todays events to show Mr. T how long it took to get him out of the persistent highs and back within range. It took 5 full hours after the first correction and an additional 8 units of insulin to start seeing stable in range BG numbers again.
Just to put it into perspective, 8 units is about 25% of Mr. T’s current total daily dose (TDD) of insulin. When the liver gets going it is a tough job counteracting it.
After it had all settled down , I remembered our DE (Diabetes educators’) advice that it is also very important to replenish the glucose stores in the liver after it has had a dumping session. It is important to “feed” the liver, so a good hearty meal matched with enough insulin is just what the doctor would have ordered.
Mr. T and his liver enjoyed his feast.
* each glucose meter has a range within which it works. For the Optimum Xceed it is between 1.1mmol/L and 27.8mmol/L. If your reading is below 1.1mmol/L the meter will show LO, if it is above 27.8mmol/L it will show HI. Please check in your own meter manual at what levels the lowest and highest reportable values have been set for that specific meter.