CDSS - Diabetic Ketoacidosis

A 45 year old female, agricultural labourer by profession who was apparently alright until July of 2018 when she developed symptoms of giddiness, headache, vomiting and generalised weakness. She went to a local rural medical practitioner (RMP) who did her random blood glucose test using a glucometer which showed "hi" (usually glucometer in India, show "hi" when blood glucose level is more than 600mg/dl) Before that she never got her blood glucose levels checked. The RMP referred to the GP where she was given oral hypoglycemic drugs among other drugs for symptomatic management and was sent home. 

She was apparently normal for a month when she again developed symptoms of vomiting and generalised weakness for which they have consulted the RMP who have referred them to the expert where she was diagnosed as Hyperosmolar Hyperglycaemic State (HHS) and was administered Inj. Insulin Mixtard (an intermediate acting insulin) and sent home after her sugar levels normalised. She was asked to take 10 units of Insulin Mixtard in the morning and 12 units in the evening.

On 13th May 2019, there was a stressful event in her home, and she happened to miss her dose of insulin followed by next day morning too. On 14th May 2019 around 11 o clock she developed symptoms of breathlessness, nausea, headache, burning micturition, abdominal discomfort, and generalised weakness. For which she was admitted in a local hospital upon consulting the RMP where she was given I.V. glucose and immediately refereed to our tertiary care hospital where the random blood sugar level came out to be 440 mg/dl

She was stabilized and up on further investigating from the treating team it has been found that she was taking Inj. Insulin Actrapid instead of the Insulin Mixtard which was the recommendation.

Based on the history that the inj which she was taking was a clear fluid where as actrapid is clear while mixtard is milky.

Owing to her history and judging by her presenting complaints, other tests were done on which the significant findings were of pH which was 7.05, pCO2 was 6.5  and urine ketone bodies were present.

Judging by all these factors she was diagnosed as Diabetic Keto Acidosis (DKA) and her treatment was started giving insulin infusion.

Her blood sugars levels, ketone body presence and arterial blood gases were monitored until she could be normalised.

The patients requested an early discharge because they were not able to afford the stay in the hospital because of the out of pocket expenditure for the patients (for both medications and stay in the hospital). 

The patients and the next to kin are unaware of her parents history of diabetes but her siblings (Brother and sister) were also diagnosed with diabetes.

CDSS of Readmission of the patient:

 12:29 - MS: The patient glucose value has given to more than 600 when she reached the hospital. She was given IV administration and tablets were given. 

Today morning when she told tablets she had vomitings, shortness of breath and dizziness.

They are thinking to come to hospital now sir.

 12:37 - SG: Do we know the reason for her Hyperglycaemic episode? Did she miss her dose?

 12:38 - MS: No bro. As what he has told me she was taking her doses regularly. I also asked are they correct medications and he said yes.

12:38 - MS: I think we need to check that

12:48 - VP: Any signs of infection?

12:49 - MS: I haven't asked him.

13:38 - RB: Do we have an image of her past discharge summary from previous hospital?

14:51 - MS: The patient relative informs she is admitted in hospital

16:18 - RB: Yes we have admitted her. 

Will keep you posted

20:35 -: have seen the case .c/o giddiness since yesterday, breathlessness since morning,2 episodes of vomiting s in the morning..

20:35 - : what to be started for her sugars??

20:35 - : present grbs 510,pr 110, bp 150/100,RR 35

20:35 - : We discussed that she needs to be begun on iv insulin DKA algorithm

20:35 - : ohk

20:35 -  : What's her blood sugar in first hour of insulin? How much fluids has she received?

20:35 - : 1lit of bolus followed by 100ml/hr

20:35 - : sir here its given ..once it is less than 250 ,add dextrose ..so should we???

20:35 - : now the grbs is 218

20:35 - : The fact that her Hba1c looks normal in the face of normal Hb means that she was well controlled at home and the current crisis is because of underlying infection going by the leucocytosis

20:35 - : Can any of you share the previous DKA protocol I had shared last time? Was unable to locate it again this time

20:35 - : This message was deleted

21:14 - : The flowchart in this is good sir

21:14 - : Her current GRBS is 122. Should I Give Dextrose and stop insulin sir ?

21:14 - : Give dextrose but don't stop insulin. If necessary give 25% or 10% dextrose.

21:19 - VP: Sir, you asked to continue insulin to prevent ketosis?

21:21 - RB: 👍

21:23 - RB: She's in ketosis. 

This is to reduce ketosis by correcting her insulin deficiency?

21:28 - RB: Currently giving 5D according to the flowchart in the PDF I shared sir

21:28 - RB: Insulin currently going in 0.5ml per hour.

21:29 - VP: How is her symptoms now sir?

21:29 - VP: which PDF sir?

21:31 -  The advantage here is that the values are not in mmol but in mg per dl

21:31 - VP: pH was very low!!

21:31 - VP: She has UTI?

21:32 - : Not sure

21:33 - VP: There were 8-10 pus cells

21:34 - : In women more than 10 would be suggestive but again uti is more likely

21:36 - : Subjectively how is she feeling now?

21:36 -  her dyspnoea subsided

21:36 - : Vomiting?

21:36 - : no fresh episodes of vomiting

21:53 - VP: Oh okay sir. Since, her HbA1c was good. She may be getting recurrent episodes of infections eg, UTI.

21:53 - VP: This message was deleted

21:53 - VP: Thanks sir

21:56 - : Not oriented to time place or person sir.

21:56 - : GCS is 15 though.

 21:56 - : yes sir we have advised for irine cultures

 21:56 - : Sharing my notes on this patient. Request discussion and inputs on it.

21:59 - VP: I liked this note sir. They have mentioned clinical reasoning behind any decision

22:43 - : Aditya's Note

07:54 - : Sir her current GRBS shot up to 362. Increased insulin to 3ml per hour

07:54 - : Re instituted 0.9 NaCl @ 250ml per hour.

07:54 - : Yes as soon as you added 25% dextrose you could have added more insulin per hour. 

In DKA one never reduces the insulin drip rate. Only dextrose needs to be adjusted

07:56 - : Urine output from 6pm to 11pm was 1400ml

07:56 - : Input from 6pm 1900ml.

07:56 - : As she has no fever. The IO chart is also covering insensible water losses indicating adequate hydration.

07:56 - : Hydration - Adequate

Bicarbonate - Not required

Insulin requirement - Matched to target 200mg/dl

Potassium - will repeat serum electrolytes

07:56 - : Urine output from 12 to 1 30 is 1000ml

07:56 - : Input also 1000ml

07:56 - : Current GRBS @ 299

07:56 - : Borderline K+

07:56 - : IMG-20190626-WA0000.jpg (file attached)

07:56 - : GRBS @ 200 at 3 am.

07:56 - : Electrolytes will be available shortly.

07:56 - : Current GRBS at 91. Administering 25D with Insulin at 0.5ml per hour.

07:56 - : GRBS at 7 was at 73. Stopped Insulin. Advised 25% Dextrose. Halfnor 1L in 1 hour.

07:56 - : Now at 249. Halfnor @ 1L an hour advised.

07:56 - : Should we now switch to S.C. insulin 2 hourly sir ?

07:56 - : Her urine for ketones is still positive (sample sent at around 12 midnight)

08:11 - : By how much does the 10% dextrose increase the blood sugars level? And how much insulin is needed to neutralize the dextrose we give?

08:11 -  Are ketones osmotically active like glucose?

08:11 - : Why is it that inspite of giving IV Insulin, the patients potassium is still normal?

08:11 - : 45 female dki

Grbs at 11 am 130 mg/dl

Increased 10d 

Currently dextrose rate 40 drops per min

08:11 - : I.e 2.5 ml/min

08:11 - : Insulin 6u/hr

08:11 - : Dki patient grbs 159 at 12 pm

08:11 - : 👍add more dextrose? Recheck ketones?

08:11 - : 25% drip rate can be managed better without increasing fluid overload?

08:11 - : In a span of 1hr that is from 11am to 12pm 10.5 gm of dextrose was delivered which increased body sugars from 130 to 152 mg/dl which means 1gm of dextrose is increasing body sugars by 2mg/dl...hope this continues further..now we are continuing the drip rate at 0.2gm of dextrose per min which will deliver 12gm od dextrose over 1hr

08:11 - : 👍any reference links?

08:11 - : sir this is wat happened in this 1hr in this pt

08:11 -  I know but any reference links to what has happened in the past 100 years to countless patients?

08:11 - : https://emj.bmj.com/content/22/7/512

08:11 - : ohk ..will luk for it

08:11 - : urine for kb sent at 11:30am is negative

08:13 - : Shall we switch to subcutaneous then? What does your protocol say?

08:13 - : Sir but I remember when we discussed the other day, the point bought out was Ketones will be taking atleast 48-72hrs to become negative?

08:13 - : Based on what past data from what studies?

08:13 - : When we were discussing about patient the last time, when her urine for ketones were negative in 1 day, I remember someone raising this point sir.

08:13 - : Ketones will be positive for atleast 48hrs.

But then have to review literature on it

08:13 - : Yes let's find what's mentioned in past literature based on previous observations by people like us

08:13 - : 1pm 196

2pm 182

3pm 171

08:13 - : So I'm stopping insulin drip 

And keeping her on hai s.c

08:13 - : Alright is she able to eat?

08:13 - : If not then you may switch her to algo 2

08:13 - : She is willing to eat

08:13 - : Grbs at 4pm 143

08:13 - : So 1.5 U per hour?

08:13 - : As long as she's out of DKA do we need to worry about correcting insulin deficiency?

08:13 - : The algo you shared is about treating high glucose and not DKA 

In DKA we would need to maintain the same amount of steady insulin flow and also infuse glucose to prevent hypoglycemia

08:13 - : ya the algo which i shared now is not for dka but i was thinking wat if her ketones were still positive then we need to have increased it

08:13 - : Check again if they are still positive. 

Actually Rotheras is a bedside test and children with type I are taught to play test it themselves

08:20 - : GRBS of Patient with DKA 315 mg/ dl

08:20 - : 8pm and 10pm?

08:20 - : Her Urine for Ketones are Positive again. Reverting to DKA Algorithm.

08:20 - : Did we continue iv insulin algorithm 1 or 2 or did we switch to subcutaneous before checking on the ketones again?

08:20 - : Is she 45 years old?

08:20 - : Yes sir.

08:20 - : Switched to Subcutaneous Sliding scale sir. Sent for Urine Ketones and once it was positive Switched to Algo 1 for DKA

08:20 - : after stopping dka protocol ..thought of starting sc insulin from night but then she dint eat in the night .. and her sugars went upto 350 so started on algo 2. and sent for urine for kb which turned out to be positive then reverted to dka algo

08:20 - : Yep.

08:20 - : However with her K+ currently at 2.9. IV insulin is stopped and only Fluids with KCL therapy is ongoing. This is according to the algorithm.

08:20 - : dextrose over 1hr???

08:20 - : No I stopped it because Insulin had to be stopped.

08:20 -  even while insulin infusion ..is it recommended to give too rapidly?

08:20 - : When Plasma Glucose reaches 200 give 5D @ 250ml per hour. If less than 200. Rapid infusion may be given.

08:20 - : Which algorithm advocates stopping insulin in DKA?

Please quote with link

08:20 - : Also 5D is not a good resuscitation fluid. So fluid overload unlikely.

08:20 - : The statement appears contradictory

08:20 - : Sir this picture taken from the PDF I shared says Hold insulin if Serum K+ less than 3.3

08:22 - : Hold Insulin? What evidence do they have for making that statement? 

Can't agree unless there is more evidence for that decision. 

It's not hypokalemia that kills but dka can

08:22 - : Also 40MeQ over one hour as per your notes is too fast for what the protocol advises?

08:22 - : Sir it's in the picture I shared. And when I looked for a reference they cited their own article. (Reference 13)

08:22 - : The picture says 20-30 MEq per hour

08:22 - : Yes sir. We are giving it over 90 mins sir. I changed it after taking the pic sir.

08:22 - : Add it in the file as a separate note and share the picture of your note again but don't change your initial note

08:22 - : Unfortunately I already did it sir. I will write it again sir

08:22 - : And remember whatever we write in our progress notes is our plan. 

What we write in the nurses order sheet is what is legally executable. 

Ideally the nurse is not supposed to execute what you write in the progress notes

08:22 - : Sir her current GRBS is 194.

08:22 - : 6 shy of the minimum mark.

08:22 - : Numbers are at best an approximation. 

There are no real validated cut offs. 

What experiments have these guidelines been based upon? Were we able to review those?

08:22 - : You can also use 10% or even 25% dextrose as the glucose drip rate can be titrated lower to prevent fluid overload and if you can share it as a thesis in 100 patients they will invite you to rewrite the guidelines

08:22 - : Okay sir. Will start with 10D over 2 hours ?

08:22 - : Either way you will need to watch her for hypoglycemia with hourly checking of sugars to anticipate how much you need to increase the dextrose drip rate to prevent hypoglycemia. 

Does your dextrose serve any other purpose right now other than preventing hypoglycemia in this patient?

08:26 - : Is she 45 years old?

08:26 - : Yes sir.

08:26 - : But the BMJ Case reporters have been thinking her to be 55 years old 🤔

https://docs.google.com/document/d/1RYmcszyce2l02vvmj2tst4cdS79bTfxnAsmOmkfohpM/mobilebasic

08:29 - : "A 55 year old female, agricultural labourer by profession"

Wish I could know more about her as a person. How does one become an agricultural laborer in Telangana? What was her career path that she followed?

09:00 - MS: The son in law told as an estimate that she would be around 55 years sir.

09:01 - MS: Polam and kuli panulu cheskuntam sir (words of patient) - agricultural and daily wage labourer sir

09:12 - : Yes that's what the English also says. 

I wanted to know her details as a person. 

How does one become an agricultural laborer in Telangana? How did she become one? 

Knowing her story in detail would enable me to connect better with her not only in this crucial critical point in her life but also hopefully later

20:35: Grbs of dki 506mg/dl

20:35: Was the insulin 6U per hour held for a longer duration?

Please tell us since when is she currently on the 6U per hour and for how long it was stopped.

Also ensure that we never stop it till the ketones are negative.

Just stop the dextrose and titrate it again at 150 and the same holds for the potassium

20:35: She was maintained on 3U/hr as her GRBS was maintaining between 200 to 300 sir. However when Serum K+ was detected to be low, that was when we had to stop insulin according to the protocol and start KCL therapy sir. At 8 her GRBS was 194 and we advised for 10D.

20:36: How long was it stopped?

20:36: for around 3hrs

20:36: and she had idli in the morning

20:36: morning urine for kb is positive

20:36: So,again iam starting insulin 6units per hr

20:36: for potassium replacement ..40meq given and sample sent ..report awaiting..should we start k+ too along with insulin or wait for k+report and then start  k+ infusion??

20:36: sir the acidosis is due to ketones is it ..but here the acidosis has improved but still the urine ketones are positive

20:36: 40MeQ only given? How much contribution does it make for her total body potassium? Use the formula?

20:36: She's still acidotic. Just CO2 is compensating

20:36: ohk

20:36: sir you said we need to target the ketonuria ..but then acidosis would be better as it would reflect the plasma ketones

20:36: and plasma ketones are more reliable than urine ketones

20:36: acc to the formula ..at k +of 2.9 she has a deficit of 85meq

20:36: Then why did we stop at 40?

20:36: That would be a nice thesis

20:36: the level of k+ rise is different im different articles sir..but in the book its given 20meq will raise serum k+ by 0.25meq

20:36: Grbs of dki patient 510mg/dl

6u /hr I.v infusion and ns infusion is going

20:36: increase insulin

20:36: How much increase would you do if this was algo 2 or 1?

20:36: 12u

20:36: In algo 1 or 2?

20:36: algo 2

20:36: Let's go slow with it and use algo 1 to escalate.

So the learning is if we need to increase insulin in DKA we use algo 1 or else we continue DKA algorithm

20:48: dka pt : grbs 283mg/dl @5:00pm

              insulin drip @4ml/hr

20:48: How many units per hour?

20:48: 4units

20:48: Are we supposed to come down below 6U in DKA ?🤔

20:48: yes sir ..we can but not below 0.05U/kg/hr

20:48: We can? How?

Don't tell me because it's given in the cookbook but let me know the logic or experimental evidence for it if available

20:48: sir u said ketosis is a reflection of insulin defeciency but why not bs can also be a predictor of it??

20:48: Now dki Grbs 310

7units/hr I.v insulin is going  according to algorithm 2

Sr.pottasium sent at 5pm __ 3.4

Urine for ketone bodies negative

20:48: Continue algo 2 👍

20:48: sir we shall continue the dka protocol till 8:30pm then again repeat urine kb and abg if kb is neg and hco 3is more than 17 and if the pt is eating then will overlap with sc if she is not eating then algo 2??

20:48: Yes both of these are dependent on insulin deficiency but while ketones can be made zero blood sugar can't

20:48: Good plan 👍

20:49: ya ..sensible!

20:49: sir only difference i notice in algo 2 and dka protocol is we are supplementing with dextrose with low BS ..

20:49: in case of dka

20:49: Also we are increasing insulin dose in case of higher sugars

20:49: with higher sugars we are anyway following algo 2 no sir even in dka

20:49: The correct English would be:

"It makes sense"

Pardon my English teaching addition to the conversation

20:49: Yes but that is not mentioned in any DKA protocol?

We just made a modification of it ourselves and will hitherto become a short note as "XYZ DKA protocol."

20:49: sir its given we can titrate it but not less than 0.05u/kg/hr

20:49: sr k+from 11am to 5pm (6hrs)has dropped to 0.5meq with 34U of insulin

20:49: Good documentation. Any literature on similar rate of fall with Insulin documented elsewhere?

20:49: sir the present k+is 3.4 ..so shall we supplement with 1amp ..hope it would increase the sr k+ by 0.5 in this pt coz previously with 40meq it increased k+ by 1meq

20:49: we can decide to maintain the target k + around 4

08:17: 45F with DKA . Urine for Ketones positive again.

08:17: Initiating DKA Algorithm 1

08:17: ph 7.5?

08:17: Current GRBS 347. Insulin infusion @ 7units per hour. Potassium 20meqs in 1 pint NS

08:17: She doesn't require bicarbonate

08:17: Yes. Apologies for the poor handwriting.

08:17: titrate insulin acc to algo 2but not less than 3ml/hr,if grbs around 170 then supplement with 10%D at 40drops per min

08:17: Okay.

08:17: 216 at 4am and just checked now her GRBS is at 49. Going by algo 2, stopped insulin and gave 25D.

08:18: 45F with DKA

S - Patient feeling well. She has no fever and able to eat

O - Hemodynamically stable with one episode of Hypoglycemia at 5am. Corrected with 25D and eventually improved to 219 at 7am. Serum K+ at 2.8. Other lab parameters within normal limits. I/O 4400/4350 at 7 am.

A - Morning urine for ketones awaited to tweak plan. ABG normal. Fluid management adequate.

P - At least 2 consecutive samples of urine should be negative for ketones. Fluid management with Dextrose supplementation and KCl supplementation as required. Encourage oral feeds.

08:18: Ketone Bodies Negative. To continue Algo 2 ?

08:18: holding the insulin for a while during k+supplementation logically makes sense coz may be if we continue insulin that would push k+  into the cells

08:18: No it doesn't because we are trying to treat insulin deficiency and not potassium deficiency caused by exogenous insulin. The logical solution for potassium deficiency caused by exogenous insulin while treating insulin deficiency would be potassium supplementation?

Question is how much potassium would one need to supplement during iv insulin administration to prevent extracellular potassium deficiency?

08:18: sir should we continue dka protocol and send another sample of urine or start with algo2??

08:18: We are already giving her a hybrid protocol combining both but let's hit the ketones (insulin deficiency) hard .

Continue DKA algorithm till three consecutive ketones are negative.

Check her hospital bills. Is she paying for all that we are doing?

08:18: yes sir she is bearing all the charges

08:18: Let's ask for academic free. Don't you feel guilty about learning so much from her for free? 🤔

08:18: and only her daughter accompanies her everytime

08:18: What's her source of income? 🤔

08:18: Above was yesterday's conversation

08:18: Below is today's

08:20: Her daughter and da daughters husband are into agriculture.. so they get money every 6 months.. Right now they borrowed money from someone else to pay their hospital bills.

08:20: She has son also but he ran away from the house.. And the patients husband is also doing agriculture

08:20: Yes her son ran away before her first admission which may have precipitated her first attack of DKA.

45F with DKA. 3 consecutive urine samples are now negative for ketones.

08:21: 45F with DKA

S - Patient feels well. Frustrated with too pricks and injections. Ate well yesterday. Wants to eat well now.

O - Hemodynamically stable. 3 consecutive samples of urine negative for ketones. 1 episode of Hypoglycemia (GRBS 39 at 4am - Improved to 146 by increasing 10D flow). She is currently on subcutaneous insulin 2 hourly. I/O 5300 / 5000 ml.

A - Mild hypokalemia (3.3) neither improving nor worsening with 40meqs every 4 hours. Occasional episodes of hypoglycemia not followed by morning hyperglycemia. Able to eat well.

P - She needs adequate hydration and glycemic control. Can deescalate to 7 point profile and HAI with Mixtard today? Needs to be properly counseled about DKA and its precipitating factors.

08:21: Is she really 45 years old? Please recheck with her relatives

08:21: Yes sir. Just confirmed.

08:21: 👍Good note

What would you counsel about her precipitating factors? What do you think is precipitating her DKA everytime she's gotten admitted?

08:21: Could suspect a UTI in a diabetic woman sir.

08:21: What's her urine culture showing? We had even visited Microbiology yesterday to look at it but I forget if we were able to trace it

08:21: What was the cause in her previous admission?

08:21: Her urine for ketones this morning is negative. 4 consecutive samples.

08:21: Her electrolytes are exactly the same.

08:21: Good. Let's put her on a physiological subcutaneous insulin regime as you suggested above

08:34: sc insulin every 2nd hrly??

08:34: No.

Before meals short acting and subcutaneous nph twelve hourly

08:34: The nph can be mixed with the short acting before breakfast and dinner

08:34: She again had one episode of hypoglycemia GRBS 58. Now @ 182

08:34: ohk sir...will calculate the requirement and accordingly advise

08:34: When is she going to have her breakfast?

09:14: sir the total dose from yesterday is coming around 128 units...and if we divide it into bd dose it’s cuming to morning 56 u and nite 30units

09:14: Bd Dose is not physiological.

She needs the short acting before every meal and the long acting only twice.

The short acting can be mixed to the long acting twice before breakfast and dinner. The lunch would need a short acting before.

We can begin with

Short acting 6U +Long acting (mixtard) 6U before breakfast, before lunch short acting depending on pre lunch, before dinner short same dose as pre breakfast but again titrated to pre meal sugar values

09:15: And we may need a rapid upward titration of each dose that I cited depending on pre injection values of the blood sugar levels

20:24: She ate 2 chapathi's at 2 pm and 25units of hai was given

20:24: Now her sugar are 111mg/dl

We didn't give insulin to her

20:24: Grbs at 6.pm 43mg/dl

Advising 25 d

20:24: put it slowly..coz again it will be difficult to know the requirement

20:24: Only half 25d was given now at 7pm sugars 341

20:24: She's very prone to hypoglycemia and it's getting difficult to predict and optimize her insulin.

I guess we will need to come down in our insulin dose and ascend in small increments. So although my plan of 6U day before yesterday was too conservative and she ended with "hi" we shall need to strike middle ground. If you look at our breakfast plan of mixtard 30 and actrapid 10 made today at 12:22 PM if you scroll the messages above, you will find that it amounts to just 19U of actrapid.

Inspite of that we calculated 25U before lunch.

Also what is her renal function? Can she tolerate long acting insulin?

20:25: When is she taking her dinner?

20:25: sir we started sc from lunch ,she hasn’t received morning dose,

20:25: Her Sr. Cr. 0.51 sir. She can for that eGFR sir.

20:25: It is 138 sir her eGFR

20:25: She will have her dinner shortly sir

20:25: Yes

20:25: What dose should we advise pre dinner sir ?

20:25: Instead of the afternoon planned 30+10 for her dinner let's come down to 20U of Mixtard (containing 6U of actrapid) and mix with 6U of actrapid.

Going by her afternoon response to actrapid it appears that the actrapid was behaving like a long acting with no obvious peak effect in two hours of her lunch but the insulin effect only peaked four hours later.

So be careful about what happens to her tonight four hours later.

Not sure why her actrapid insulin kinetics has changed. Is it a problem with the company? What brand is she getting? Or is it a problem with her body's response?

20:25: Current GRBS 114

20:25: Wait a minute.

From 7 PM with her sugar of 341 how did it come down to 114 now?

Is this after her pre dinner insulin already taken?

20:25: It was given right before her dinner sir. And this value is right after dinner sir.

20:25: 114 right after?

20:25: Dinner was somewhere around 9:00 PM?

20:25: Started at 9 05 and ended at around 9 20 sir

20:25: OMG. It appears that her previous insulin was still actively bringing her sugars down.

Somehow that short acting actrapid 25U before lunch is having a longer effect of hypoglycemia.

Please watch out hourly. Does have hypoglycemia unawareness too? Are we able to see symptoms when we find her to be 40-50 or are these incidental detections?

20:25: No sir. She never reported symptoms of hypoglycemia during my watch.

20:25: Even during my duty I was consistently asking about hypoglycaemic symptoms but she didn't tell any

20:25: 126 now sir

20:25: Current GRBS 120

20:25: Current GRBS 98

20:25: 10D on Standby.

20:25: Current GRBS @ 45. Advising 10D slowly to keep it non aggressive.

20:25: Still @ 47. Increasing 10D  before I move over to 25D.

20:25: Now @ 122

20:25: Did not need 25D.

20:25: Current GRBS @ 87. Slightly increased 10D to maintain it there.

20:25: Now @ 197. Maintenance with 10D ongoing.

20:25: Now @ 89mg/dl. 10D is being titrated accordingly.

20:25: GRBS now @ 312. Stopped 10D completely.

20:26: Looks like we shall need to avoid any long acting insulin in her completely as even the short acting insulin is behaving like long acting in her system although her eGFR appears normal (btw what was the date of that creatinine test?)

8:54: Sir nw grbs is 231 

How much insulin to be given sir ?

Ystdy (1/07/2019) after giving 6u in mrng sir

8:55: Yes but yesterday she was also under the influence of day before yesterday's mixtard and day before yesterday she had had hypoglycemia at night early morning which seems to have worn off yesterday night early morning. 

I was thinking we can give her 8U before breakfast today but let's give her 6U before breakfast now

02/07/2019

8:33: Looks like her 12U before lunch was going strong acting for long to dip her morning sugars. I guess she remains unaware of her hypoglycemia every time we record it?