Saturday, October 2, 2010

Music; Adventures in Insulin Therapy (Math Re-Mix)

It's been a couple of crazy weeks: everyone in our household has had respiratory crud with fever, all of us have seen our doctors with extreme fevers. My MIL thought it would be fun to add in a major health crisis (I kid; she can't help it) and she's been in the hospital for two weeks while her OLDER brother was here visiting so the monkeys have been running the asylum. Uncle Father Fred is a retired catholic priest and completely incapable of thinking of much other than himself, his priestly world and Hawaii (he spends about six months there every year...he's never taken me).

I don't want you to miss the trees for a forest so let's get to it:

I have a lot of really good new stuff but I have fallen in love with something that is a complete surprise.
Begonias by Caitlin Cary and Thad Cockrell. Caitlin Cary along with Ryan Adams and others formed up Whiskeytown which preceded Ryan Adams's efforts with the Cardinals which I like very much. Like Whiskeytown, Begonias is alt-country for real; the steel guitar whine keeps us from any delusion. I never saw my tastes heading down this road but this is a cd full of *really* good songs and stunning harmonies. Cary's voice shimmers as Cockrell's advances the melody; it's a great pairing. I listen to the entire disc very often. I hear lots of Tom Petty in the chunky guitar sounds. I have a special affection for "Something Less than Something More".... it reminds me a lot of Tift Merritt's "Trouble Over Me" with its almost apologetic request for at least the appearance of love. Heartbreak done exceptionally well.

Adventures in Insulin Therapy
That Other Thing (TOT) has been ill along with the rest of us. Type 1 diabetics are by definition folks with immunity challenges so it hit her harder than the rest of us. At first her blood glucose levels were terribly low: what little food she was eating wasn't absorbing as usual so her insulin needs were really tough to gauge. Once the fever was gone she still had a bit of cough and sniffles so I kept her home for what I thought would be one more day to keep her from causing an outbreak.

That day I detected the tell-tale smell of ketones on her breath: high blood sugar? Really? She'd been so low for days. So I sent her off to see if she had ketones in her urine: HUGE. Bad, bad. We got a bunch of insulin in, had drinks and waited to see what would happen. Scary stuff. Long story short: we determined that, at least for now, her insulin dosages are increased about 200% across the board.

Glucose metabolism isn't as straight forward as many think, especially when your diet has been shifted to omit wheat flours---seems all the substitutes have metabolic challenges. So I thought I would share a little bit of insulin math with you. I'll present our insulin calculations for know, that sleepy meal before you're thinking clearly.

Background: TOT is currently on a multiple daily injection regimen. This means she gets insulin in two or three formulations at least five times per day and mostly more. They fall into two general classes: slow rising, long acting insulin that is referred to as "basal" and is meant to serve the purpose of metabolizing sugars pumped into the blood stream by the liver...just regular stuff we all do. Basal insulin supposedly has no peak and acts for 24-hours. We've found we don't get good results unless we divide her daily basal into two injections: day and night. The second type are faster and shorter acting insulins that are given with food or given to quickly reduce high blood sugars. Some of them peak faster and are used up fast, some stay around longer and peak lower.

Before Wednesday, Lindsay was receiving 1 unit of insulin for every 25 g of carbohydrates at breakfast time and 1 unit per 22g carbohydrates at all other times of day. She had a correction factor of 1:90 - 100 mg/dl, meaning if her blood sugar is high she should have 1 unit of insulin for every 100mg/dl in excess of her target blood glucose which is now 150 mg/dl.


TOT wanted to have Cinnamon Rice Chex (CRC) for breakfast. Its one of the few cereals we've found that will accommodate her grain restrictions and doesn't bedevil us with glucose challenges we just can not manage. General Mills reports that CRC has 25g of carbohydrates per serving which they put at 30g of cereal. ha. We put a bowl on a scale and put cereal in the bowl until TOT said when. 52 grams of cereal.

52 grams of cereal/30 grams of cereal per serving means we were looking at 1.73 "servings" of CRC.

1.73 servings at 25 grams of carbohydrates per serving gives us a meal of 43 grams of carbs.

At breakfast TOT uses an insulin to carb ration of 1:25 since she's usually more sensitive to insulin in the AM, but we were late getting up so we used a factor of 1:22. With 43 grams of carbs, that gives us a need for 2 units of insulin. Since she's been ill, however, we've had to increase her bolus ratios by about 150 - 200% so we were looking at about 3 - 4 units; we could call it 3.5 units and be close.

We know that CRC tends to have two metabolic peaks: a fast, high peak and then a long period of no glucose making it into the blood stream for about 4 hours when we see a smaller increase that sustains for a while. That puts us in the position of having to use two different "fast-acting" insulins to get both a fast insulin peak and a later increase that lasts a while---all while not overdoing the shorter insulin and ending up with a huge and dangerous drop in blood glucose while we wait for the rest of the sugar to go live. Experience has shown us that Lindsay can eat CRC with a 1:2 ratio of Novolog (high peak and short activity) to Regular (lower peaks, longer activity).

A 1:2 ratio applied to 3 units would give a neat and easy to measure accurately dose of 1 unit Novolog and 2 units Regular. We'd need to try to finesse a bit more of each to get to 3.5 - 4 units. Our syringes have 0.5 unit scales but are really tough to eke out small differences. Of course we might use our handy injector pens except Regular doesn't come in a pen and never mind: with pens its a half-unit click or nada; no wiggle room. We won't know for certain whether our assumptions and estimates are correct for 6 hours because that's how long it takes to clear all of the insulin we'll give her. Of course we could always check midway and try to regress blood glucose against what insulin we think is still active... graduate level statistics, that.

So that's the cereal. We needed to measure her blood sugar to see if we needed a correction factor. Holy Cow, her blood sugar was 350! Wow. Two units of extra Novolog for that correction in usual times but we're needing a more these days...still, I'm reluctant to double a 2 unit correction so I go for 150%: 3 units of Novolog to correct before bolusing for food.

So there we are:
Fast peaking short acting insulin in the amount of about 1 for cereal and 3 for correction: about 4 units

Slower peaking, longer acting insulin in the amount of about 2 but probably closer to 2.5 to hedge the measuring challenges.

Two injections almost ready to go. But guess what? There's not one more vial of Regular in the fridge. I was wrong. And without Regular, there's no cereal. So we start over with a different menu.

Thanks for taking this adventure with us! Our insulin pump is supposed to arrive on Monday but we can't begin to use it until we get further word from the insurance company about their coverage and not until we see our doctor for the start-up session. The pump should help a LOT with this stuff. But that's another adventure.


KSM said...

I hope everyone is on the up and up now?

KHM said...

Hope springs eternal, KSM. We can be confident of that much.

Special K said...

Life + Math = ):

Good thing her mom is good at Math! If that were my kid, I'd be all... "I don't know fractions, kid. Have some lettuce."

Anonymous said...

Dear Cousin Kathy Jean............YOU ARE MY HERO!!

Love you, Cousin Caddy Jean

KHM said...

Awww, Caddy Jean: there's nothing a bit heroic about giving your children what they need to grow up in good health OR loving good music. But I'll take your words as an indication that I've had plenty of good role models from the Dillard side of my family.

Love you!