Bobbyís blood glucose level is over 400, what do I do?
In a comparative sense, what we need to do with a low blood sugar level is logical and becomes somewhat automatic. The answer to the question, ‘What do I do with a low sugar or glucose level (hypoglycemia) is answered by the demand for immediate attention with efforts to increase the amount of sugar in the blood stream (see instructions on hypoglycemia)?’.
What to do with a high glucose or sugar level (hyperglycemia) is less automatic or obvious. High glucose values are of concern for one of two reasons. In general they are of concern because, over years, they can cause diabetes complications. Second and less common, a high glucose value can alternatively be of concern because it may be a sign of an immediate problem and a change in metabolism such as the recent onset of an underlying illness that may lead over the next day or two to dehydration, ketosis, and possibly ketoacidosis. An elevated glucose value can also be a transient event that needs to be recorded but does not require any immediate or even long term changes in the program.
Preventing (as opposed to treating) hyperglycemia is important because it is the first step in preventing chronic complications of diabetes. This requires a clear understanding of the pattern of glucose over weeks and making appropriate adjustments in diet and insulin program alternatively, it might indicate a chronic problem needing some thought and adjustment in the management program.
Knowing if hyperglycemia is a sign of an underlying illness or sign of a major change in metabolism is important because this may indicate that a change in the management plan is made in the next few hours. Being aware that random high blood glucose value can occur and not require any immediate or long term intervention is important to prevent undo anxiety and inappropriate action (such as sending the child home from school). There is no clear definition of what a ‘very high value’ is, but commonly values above 250 are considered high and values above 300 are considered very high. The real answer to the question lies not in the absolute value but in your assessment of your child. For example, if the value is 450, but your child is feeling fine and has no ketones in the urine, then this value represents recent absorption of a lot of sugar or other carbohydrates that was not well covered by the available insulin. Or if your child is on an insulin pump, this could represent a sign that there has been a very recent interruption in insulin flow from the pump. In such instance, an effort to try to uncover any recent change in the diet or examination of the pump infusion site is important and would be helpful but no immediate therapy for that number is needed. Alternatively, if your child’s glucose is 276, but s/he has moderate ketones, is feeling ill and has a fever, then this glucose value represents a change from normal in his metabolism with evidence for absolute or relative insulin deficiency and he would benefit from immediate therapy.
When the glucose value is high, your assessment needs to include:
1. A general assessment of overall health
a. Is the child/adolescent well or ill
b. Is there a fever?
c. Is there any nausea or vomiting?
2. An assessment of urine ketones If this is a persistent or recurring problem, than a review of the insulin dosing over the last 24 hours and past week needs to be done with the management team to determine it there is a need for a change in the insulin infusion if your child is using a pump if the glucose values have been elevated on more than 2 tests over the past 4 hours or a change in the management program.
If your child is ill, then the ‘sick day management guide’ needs to be reviewed and followed. If your child is feeling fine and is ketone negative, then he may only needs access to extra fluids, may need to void more frequently than usual at that moment, and needs more close follow-up with repeat glucose and ketone evaluations at 2 to 3 hour intervals. In this instance, the high glucose is of concern as it may indicate a change in the pattern of glucose control but it is not of concern because there is risk that it endangers the individual at that moment. If it persists, than contact with your diabetes management program will be important in the next days or weeks. If you decide to contact us, you will need to provide us with the most recent glucose value (within the past 30 minutes), urine ketone test result, and your assessment of your child’s overall health. If the glucose values have been elevated for the past few weeks and this represents change in usual values, then it will be important to set-up an appointment to review this change to determine the cause and establish a new treatment plan.
Wide fluctuations in blood glucose is one of the most frustrating problems parents, children, and adolescents often face when trying to control diabetes. These often occur despite all efforts to follow the diet, activity, and regular insulin program. In a person without diabetes, the pancreas and counter-regulatory hormonal systems (cortisol, growth hormone, epinephrine, norepinephrine, and glucagon) are finely tuned to respond to the circulating serum blood sugar value. This is because the absorption of the food from the diet is quite irregular, depending upon the type of foods, the combination of foods eaten, the rate of stomach emptying, the time of day food is eaten, and the activity before and after the meal. The emotional state of the child may also affect food absorption and use. In a person without diabetes, the amount of sugar that is being absorbed from the intestine is immediately mixed with the amount of insulin needed coming from the pancreas to regulate the use of that sugar by the liver and body tissues. The pancreas increases its insulin output within minutes, as blood sugar rises and decreases the insulin output as quickly, when blood sugar falls. In addition, if blood sugar falls too low, counter-regulatory hormones come into play to help raise the blood sugar. As a consequence, this system may be making hundreds of adjustments each day. In a child with diabetes, we cannot give 100 injections each day. We attempt to simplify the system by limiting the number of insulin injections to three or four. As a result, we become dependent on the meal and activity programs being scheduled around the expected absorption of insulin. However, many things can still change or cause variability, even when things are being followed fairly regularly. Variations in the fiber content of the meal will change the absorption of glucose from that meal, and the relative “free-sugar value” or “glycemic index” of a food within an exchange may differ considerably from one food value to another, even within that same exchange group, giving very different blood sugar values. In addition, stomach emptying can vary from time to time, with the stomach emptying very rapidly in some instances and very slowly at other times. This too will change the sugar absorption pattern. Another variability is insulin absorption. While we have a reasonably good understanding of the usual and normal absorption pattern of insulin from any one site, there are variations from individual to individual and from site to site in a single individual. Those variabilities can also be influenced by the amount of activity. Increased leg movements such as running will change insulin absorption from the legs. Even if activities are consistent and the injection site remains constant, slight differences in the depth of the injection can cause differences in the absorption of insulin. Even the temperature of the skin can affect the injection and the absorption of insulin, i.e., insulin that is injected into a site exposed to a warm bath or a hot tub will have increased insulin absorption, while if that site is exposed to a cooler environment, such as immersion in a swimming pool or exposure to a cold day, the insulin absorption will be slower. Finally, in a few individuals, there is a residual, very small amount of insulin secretion from the pancreas that can occur. This may be somewhat intermittent in character. This residual insulin secretion is not as finely tuned to the blood sugar levels as insulin secretion in the normal individual. Thus, this basal amount of insulin may help keep the blood sugar under control in many instances, but may also contribute to some variability, causing both hypoglycemia and hyperglycemia. These “normal” fluctuations in blood sugar alone can also be exaggerated by both internal and external stresses. For example, if the blood sugar begins to drop in an individual, causing hypoglycemia, the normal response of the individual is to release glucagon and other counter-regulatory hormones to raise the blood sugar. Some individuals tend to respond excessively with an overabundance of these hormones, driving the blood sugar output from the liver to very high amounts. In the person without diabetes, these individuals would then counter with extra pancreatic insulin to keep the blood sugar from going too high. In the person with diabetes, there is no insulin reserve that will suddenly be made available in these circumstances, and hyperglycemia can result. In addition, in an effort to treat hypoglycemia, it is common to give too much glucose, which can drive glucose levels up later in the day. If we are dealing with a child who has a “bouncing blood sugar,” we attempt to manage this by a number of ways: (1) We need to identify the times when the child is most likely to be hypoglycemic and cover those periods appropriately with diet management, if at all possible; (2) we try to change the insulin dose to lesson the likelihood of both hyperglycemia and hypoglycemia. By making adjustments in the amount, mixture, and the administration schedule, this often can be accomplished. On occasions, this may mean an additional shot at lunch or late in the evening; (3) we can look carefully at the day-to-day schedule to make mealtime and activity as consistent as possible; (4) when treatment for low blood sugar is necessary, we can try to avoid “over-treating” with excess glucose. In all cases, we try to balance the program so that the child is functioning in his/her school, family, and neighborhood normally without showing significant episodes of hypoglycemia, nor showing severe hyperglycemia with ketosis. If we need to “loosen” the schedule because of hypoglycemia, this may only be temporary during a few months in the summer, for a few years during early infancy or childhood, or again during the growth spurt during adolescence. More appropriate tighter control regime is reimplemented when possible. Alternatively, if the degree of control we have is extremely poor, we may need to try to become more regimented with our schedule. Each child is different and each child will experience different problems at different times.