Sick day Guidance for Insulin Pump Users
You may experience high blood glucose while using your insulin pump. It is important to know why this might occur and how you can manage it.
Reasons for high blood glucose levels fall into three main categories for an insulin pump user.
-
Increased insulin requirements
- Infection
- Illness
- Stress
- Inflammation at the insertion site
- Reduced exercise
- Pregnancy
- Steroids
- Having a period
-
Infusion set
- Insertion into a hardened area
- Infusion set left in too long
- Infusion set dislodged
- Infusion set blocked
- Empty cartridge
- Large air bubble in tubing
- Infusion set leaking
- Pump failure
-
Insufficient insulin delivery
- Basal rate too low
- Forgot to give bolus
- Incorrect insulin to carbohydrate ratio/underestimated carbohydrate content of food
- Excessive carbohydrates after hypoglycaemia
- Rebound high blood glucose level following hypoglycaemia
- Pump stopped working
- Insulin expired
- Insulin exposed to extreme temperatures
To follow this advice, it is important you know:
- Your most recent weight in kilograms or your total daily dose of insulin so that you can give the correct insulin dose to correct ketones.
- Know 10% and 20% of your TDD beforehand so that you know what to do if you become unwell.
It is very important that you know what to do when you are ill. This is a guide but please follow the advice of your local diabetes team if given. Advice may vary slightly from this content.
Supplies you need access to (as part of your kit box if you have one):
Please ensure you have access to the following at all times, not just when you are unwell.
- 1-month supply of all insulin cartridges
- Pens or syringes. You should have access to long-acting and quick-acting insulin to use in case of pump failure
- Blood glucose meter with 1-month supply of test sticks/strips and lancets – check the sticks/strips/lancets have not expired
- If you use continuous or flash glucose monitoring systems (Dexcom/ Freestyle Libre) ensure you have access to back up blood glucose meter and test strips
- Ketone test kits – either urine or blood – check the ketone test strips have not expired
What do ketones mean?
In the absence of sufficient insulin, the body’s cells cannot use glucose for energy. The cells will then switch to an alternative energy source and body fat will be broken down to supply the necessary energy.
This rapid breakdown of fat can cause the build-up of substances known as ketones. Eventually, the ketones rise to levels that cause the blood to become acidic and this is known as diabetic ketoacidosis (DKA). The only treatment for DKA is insulin and fluids.
Ketones can be measured in urine by Ketostix or in blood by using a blood ketone meter which is more accurate. It is advisable to check the expiry date on urine and blood strips before use. Many diabetes centres recommend you use a blood ketone meter.
Remember: now you are on a pump, you have no long-acting insulin and ketones will be produced within a few hours if there is insufficient insulin delivered. You will become unwell more quickly on a pump and action needs to be taken immediately.
As DKA can develop and progress quickly and makes you feel very unwell, the next section gives guidelines for you to follow if you are ill.
Check your blood for ketones if you are feeling unwell and blood glucose levels are over 13 mmol/L.
What should I do if I have a positive ketone test? (greater than 0.6 mmol/L but less than 1.5mmol/L)
- You should take a correction dose using your pump using your ISF ratio .
- Drink plenty of water or sugar-free fluid.
- Recheck your glucose and ketones after 2 hours
- If the blood glucose is unchanged or rising:
- Give a correction dose with a pen device
- Change the infusion set and check pump settings
- Consider temp basal increase.
- Try to identify the cause of high blood glucose and seek help or treatment as necessary.
- Check blood glucose and ketones every 1–2 hours.
- Take additional correction doses of insulin as per your diabetes team guidance until blood is negative for ketones.
- Remember you should not exercise if ketones are present.
- Contact the diabetes team if high blood glucose levels and ketones persist.
Contact your GP or Accident and Emergency if you are vomiting as dehydration may occur.
Managing high blood glucose without ketones
- If your blood glucose level is above 13 mmol/L and your ketone test is negative take your usual correction dose via your pump.
- Drink plenty of water or sugar-free fluid.
- Try to identify the cause of high blood glucose and seek help or treatment as necessary.
- Check blood glucose and ketones every 1–2 hours. If your blood glucose remains above 13 mmol/L:
- Take your normal correction dose with an insulin pen device.
- Change the infusion set (“if in doubt, change it out”).
- Check for ketones: if ketones are positive, treat as per “What should I do if I have a positive ketone test” above.
- Do not go to bed:
- Until blood glucose levels are normal
- Or within 2 hours of a set change
- If in any doubt about insulin pump convert to pen devices as per your diabetes team guidelines.
See the sick day flowchart from DAFNE for people using insulin pump therapy here.
Remember
1. If you become unwell:
- While you are unwell it is VERY likely you will need to take more insulin
- Even if you are vomiting you must NEVER stop taking your insulin
- Monitor your urine or blood for ketones every 2 hours
- Monitor blood sugar levels every 2 hours
- Drink at least ½ cup (100mls) of water every hour, but you can also drink any other sugar free drinks
- Please do not fast. Try to eat some food that contains carbohydrates e.g. yoghurt, toast, ice cream, and cereal
- If you are worried about other symptoms not related to your diabetes, please seek medical advice from NHS 111 in the first instance
- You will need face-to-face medical attention if you are continuously vomiting for more than 4-6hrs or if your ketone levels in blood or urine are not reducing despite following sick day rules
2. Management of unexplained high blood glucose (hyperglycemia):
- Check blood glucose in two hours – if no change or glucose is higher, take a correction dose of rapid-acting insulin with a pen and check for ketones
- Change infusion set and reservoir (start new pod if using Omnipod® pump)
- Check glucose and ketones in two hours and take a correction bolus via pump if required, check for ketones if glucose is still over 13mmol/L
- Follow sick day rules if ketones are present
- Do not go to sleep:
- with unexplained hyperglycaemia which has not resolved
- or, within two hours of a new set change
3. In the event of insulin pump failure:
- The emergency basal insulin dose via pens/syringes would be the same as your total daily basal insulin on the pump (e.g. total basal insulin 20 units on pump – if using Levemir start injections 10 units in the morning & 10 units in the evening, if using Lantus, start 20 units once a day injections)
- Your insulin carbohydrate ratio (for meals) and insulin sensitivity factor (for corrections) would be the same as on the pump
- In the event of pump failure and not being able to access long-acting insulin you should check your glucose levels and give an injection of quick-acting insulin every 3 hours
- If you suspect the pump is not administering insulin (pump failure), you should revert back to insulin injections with pens/syringe
