Sick Days - Pump

Sick Day Protocol (pump)

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Managing your diabetes and keeping your blood sugar under control while you are sick or recovering from surgery or an injury can be a challenge. We have come up with the following sick day plan to help you. But first ...

When you have diabetes and you are sick, you need to be able to at least keep fluids down. If you are vomiting and cannot keep fluids down, you need to go to the nearest emergency room.

Patients using an insulin pump are at increased risk of ketoacidosis

Remember, when you are using an insulin pump, you have no long-acting insulin in your system. If your infusion set becomes dislodged or is in a site that has a lot of scar tissue or if your insulin is defective (i.e., from exposure to temperature extremes)your blood sugar can rise rapidly, leading to diabetic ketoacidosis.

Another reason for ketoacidosis is a site infection. You should never keep the same infusion set in for longer than 3 days. When a foreign object is introduced into the body, there is the potential for infection. Keeping sets in for longer than three days increases this risk. If the site from an infusion set becomes red, tender, warm to the touch or starts draining purulent material ("pus)", remove the infusion set and cartridge, reinsert in another location, even if you have just recently moved it, and call our office. Local or oral antibiotics may be needed. You can develop an abscess, serious enough to require surgical drainage. If the infusion site becomes red, hard, tender and if you develop a fever, call our office or go to the ER for further evaluation and treatment.

For any blood sugar >250 mg/dl, check your infusion site, give a correction bolus and then recheck the blood sugar in one hour. If your blood sugar is greater than 250 mg/dl two times in a row, give yourself a correction dose using a syringe (you need to have some!)and change your infusion set and cartridge (even if you have recently changed them). You may not be getting your insulin. Also, for any blood sugar >250 mg/dl, check your urine for ketones,and follow the "sick day" rules below, even if you are not "sick." Keep your pump basal rate going, but all boluses per this protocol should be given using a syringe, until the urine ketones have cleared. If your pump has failed, then you need to start replacing your basal insulin using injections as well.

Taking insulin and other diabetes medications while sick

If you are ill, injured or having surgery and if you are taking glucophage (metformin) STOP this medication until you are recovered.

In order to follow this protocol you will need to know 5%, 10% and 20% of your Total Daily Dose of Insulin (TDD). We may have already done this calculation for you at an office visit. If not, check your pump history and find your TDD for the last 3 days, and then calculate the average of the 3 days.

Now calculate the 5%, 10% and 20% amounts:

5% of your TDD

  • TDD x 0.05 = _________________ units

10% of your TDD

  • TDD x 0.10 = _________________ units

20% of your TDD

  • TDD x 0.20 = _________________ units

Here is what to do when you are ill, injured, under severe stress and in particular if you are showing ketones in the urine:

  • Check your blood sugar and urine ketones every 4 hours; you need to think about taking BOLUS insulin every 4 hours or so as well, even at night. We suggest that you think about taking BOLUS insulin at breakfast-time, lunchtime, suppertime, bedtime, midnight and 4:00 am.
  • If your blood sugar is less than 150 mg/dl remember to eat or drink something with carbohydrates (see the attached list).
  • If your blood sugar is less than 70 mg/dl please follow the hypoglycemia protocol.
  • Calculate the amount of insulin you will need to correct for your blood sugar and the amount you will need to cover your carbohydrates, as you would any other time. If you are not eating, then of course there are no carbohydrates to cover.
  • Check your urine for ketones. If there are no ketones or trace ketones you will take your normal amount of BOLUS insulin every 4 hours. In addition:
  • If there are small ketones in your urine add 5% of your TDD to the insulin you will be taking every 4 hours.
  • If there are moderate ketones in your urine add 10% of your TDD to the insulin you will be taking every 4 hours.
  • If there are large ketones in your urine add 20% of your TDD to the insulin you will be taking every 4 hours.
  • Drink at least 8 ounces of calorie free fluids every hour while awake. You can drink diet soda, water, broth or sugar free Kool Aid. Bouillon, consomme´ and clear soups also provide sodium and electrolytes – try also to drink some of these 3-4 times during the sick days while you are awake.

Testing the urine for ketones - In order to check your urine for ketones you will need to have ketostix, which should be available over the counter in any pharmacy. It is better to buy ketostix that are individually wrapped as they have a longer shelf life after being opened. Be sure to have ketostix on hand all the time – keep a couple in your glucose testing kit. Don’t wait until you are sick to go out and buy them! To use ketostix either pass the stick through your urine stream or collect a small amount of urine in a cup and dip the stick in the urine. Follow the directions on the bottle to see if you have ketones and how much.

Food and eating

While you are sick or convalescing you may not feel like eating. Just as it is important to continue to take your insulin it is important to continue to eat to get the carbohydrates that your body needs. If you can’t eat the foods you normally enjoy try substituting from the following list of foods. Try to consume at least 50 grams of carbohydrate every 3-4 hours. You need not eat all the food at one sitting - stretch it out over a couple of hours if that is easier for you.

The following foods give you 15 grams of carbohydrate a serving:

  • 1/2 cup of orange, grapefruit or apple juice
  • 1/3 cup grape juice
  • 1/2 cup regular soda (gingerale, coke, 7-up) at room temperature
  • 1/2 of a double stick popsicle
  • 5 pieces of hard candy
  • 1 Tablespoon or sugar, corn syrup or honey
  • 1 cup of milk or buttermilk
  • 1 cup of plain yogurt
  • 1 slice toast
  • 1/2 cup cooked cereal
  • 1/2 cup cream soup
  • 1/3 cup fat free frozen yogurt
  • 1/4 cup sherbet
  • 6 crackers or melba toast
  • 1/2 cup sweetened gelatin
  • 1/4 cup regular pudding
  • 1 cup of gatorade (also replaces electrolytes)

Your illness and other medications

The instructions we have given you are to help you manage your diabetes while you are sick with other illnesses or recovering from an injury or surgery. You should also be following the instructions of your primary care doctor, surgeon or any other doctor involved in the treatment of your illness or injury. Please refer to these doctors when you have questions about your other medications, treatments or your illness itself.

The following list includes over the counter medications that will not affect your diabetes. Before you take them it is important that you refer to your primary care physician or surgeon to be sure that they are appropriate for your particular illness. When you talk to your primary care physician or surgeon, be sure to remind them that you have diabetes and that your endocrinologist has approved the following medications as safe to use for a person with diabetes:

  • Allergies or runny nose – antihistamines or decongestants tablets, not syrups (ie. Dimetapp)
  • Congestion – Vicks Vaporub, saline nasal spray, short acting Sudafed
  • Constipation – laxative (ie. Colace, senekot, other OTC laxatives)
  • Dry Hacking Cough – antitussive (ie. Delsym)
  • Wet Cough – expectorant (ie. Diabetic Tussin)
  • Headache – aspirin, acetaminophen or ibuprofen
  • Fever – aspirin, acetaminophen or ibuprofen
  • Heartburn – sugar free antacids, Mylanta, PeptoBismol or low dose Tagamet, Zantac or Axid
  • Nausea/Vomiting - bland foods, clear liquids
  • Sore Throat – warm salt water gargles, chloraseptic spray, sugar free throat lozenges.

All the above are suggestions and are not meant to replace the advice of your physicians. And remember, if there is something seriously wrong with you, call your primary care physician or go to your nearest emergency room, as everybody else would.