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Sick day rules for hybrid closed loop (T:slim X2) users

Sickness is an unavoidable part of everyday life. The body’s natural response to illness results in higher blood glucose levels due to the release of stress hormones. When you are ill, you will need frequent blood glucose monitoring and often more insulin than usual.

What are ketones?

Ketones are acids which can make you feel very sick. They are produced when body is not getting enough food (glucose), or your body is not able to use glucose due to lack of insulin.

If you do not get rid of ketones, you can become dehydrated and eventually develop diabetic ketoacidosis (DKA).

Information:

Check for ketones whenever you are ill, regardless of your glucose levels, as you can have raised ketones with normal glucose levels, for example, starvation ketones with a vomiting or diarrhoea bug.

Sick day rules

  1. Never stop the insulin. Even if you are eating less than normal, your body needs insulin to use glucose and to get rid of ketones.
  2. Check your blood glucoses more frequently, this means every 2 hours including throughout the night.
  3. Check for blood ketones. Give additional fast acting insulin every 2 hours if blood glucose is above target.
  4. If ketones are present when blood glucose is low, they are called ‘starvation ketones’ and respond to drinking extra fluids containing sugar.This can happen in illnesses such as diarrhoea and vomiting bugs. Monitor blood glucose very closely and extra insulin may be required when blood glucose starts rising.Treat hypoglycaemia (blood glucose less than 4.0 mmol/L) as you usually do. Contact the hospital for advice if struggling to keep blood glucose over 5 mmol/L.
  5. Keep well hydrated by drinking plenty of fluids:
  • Water or sugar-free fluids are probably most appropriate in the majority of cases where blood glucose levels are normal or high
  • If blood glucose levels are low, drinks containing sugar are required, or eat carbohydrates if possible
  • Avoid carbonated drinks if possible
  1. Inform the diabetes team early to seek advice.

Using an insulin pump

You should make standard checks on the pump for blockages (occlusions), disconnection and battery failures.

Give correction doses through the pump if blood ketone levels are less than 0.6mmol/L. If one correction dose given through the pump has no effect in 1 hour, repeat the correction dose with an insulin pen.

If blood ketones levels are 0.6mmol/L or more, give correction doses with an insulin pen.

You should contact the hospital if:
  • You are not confident in managing high ketone levels
  • Your child is vomiting
  • Ketones are over 1.5 mmol/L, regardless of blood sugar levels, for 6 hours or more when following the sick day rules advice.

Contacts

  • Diabetes nurses 0114 271 7320 (Monday to Friday 8am to 4pm) or Out of hours on call doctor 0114 271 7000
  • If your child is seriously unwell and it’s an emergency, call 999.

T-Slim settings for sick day rules

Step 1 — Test ketones and blood sugar

Ketones 0.0 to 0.5

If blood sugar is high, have you changed your cannula?

Ketones 0.6 to 1.0

  1. Change your cannula
  2. Turn on SICK 130 profile
  3. Give a 10% TDD correction via an insulin pen
  4. Move to Step 2.

Ketones over 1.5

  1. Change your cannula
  2. Turn on SICK 150 profile
  3. Give a 20% TDD correction via an insulin pen
  4. Move to Step 2.

Step 2 — Check ketones and blood sugar in 2 hours and reassess

Ketones 0.0 to 0.5

  1. Turn on PROFILE 1
  2. Continue normal management

Ketones 0.6 to 1.0

  1. Turn on SICK 130 profile
  2. Give a 10% TDD correction via an insulin pen

Ketones over 1.5

  1. Turn on SICK 150 profile
  2. Give a 20% TDD correction via an insulin pen
Remember
  • Repeat this process every 2 hours if needed
  • Always call us for help if needed

0114 271 7320 Monday to Friday 8am to 4pm. Out of hours call 0114 271 7000 – Ask for medical registrar on call


Dosing guide

Section A –Ketones 0.0 to 0.5mmol/L and blood glucose more than 8.0mmol/L

Basal: Continue usual insulin basal rate (Profile 1)

Corrections: Give usual correction doses for high blood glucose levels (using your pump settings)

Cannula: Change your pump cannula if you think there is a problem with your pump

Food: If you are eating, have your usual amount of insulin for carbs in addition to the correction

Advice

  • Re-check blood glucose and ketones regularly if unwell
  • If ketones are 0.0 to 0.5mmol/L continue advice in section A.
  • If ketones are 0.6 to 1.4mmol/L and blood glucose is more than 8.0mmol/L, follow advice in section B.
  • If ketones are 1.5mmol/L or more and blood glucose is more than 8.0mmol/L, continue advice in section C.
Section B – Ketones 0.6 to 1.4mmol/L and blood glucose more than 8.0mmol/L

Basal: Turn on Sick 130 profile for 2 hours

Corrections: Calculate your Total Daily Dose (TDD) and give 10% of TDD as a correction with an insulin pen (instead of giving via pump)

Cannula: Change your pump cannula if you think there is a problem with your pump

Food: If you are eating, have your usual amount of insulin for carbs in addition to the 10% TDD correction

Advice

  • Re-check blood glucose and ketones every 2 hours.
  • If ketones are 0.0 to 0.5mmol/L follow advice in section A.
  • If ketones are 0.6 to 1.4mmol/L and blood glucose is more than 8.0mmol/L, continue advice in section B.
  • If ketones are 1.5mmol/L or more and blood glucose is more than 8.0mmol/L, follow advice in section C.
Section C – Ketones more than 1.5mmol/L and blood glucose more than 8.0mmol/L

Basal: Turn on SICK 150 profile for 2 hours

Corrections: Calculate your Total Daily Dose (TDD) and give 20% of TDD as a correction with an insulin pen (instead of giving via pump)

Cannula: Change your pump cannula if you think there is a problem with your pump

Food: If you are eating, have your usual amount of insulin for carbs in addition to the 20% TDD correction

Advice

  • Re-check blood glucose and ketones every 2 hours.
  • If ketones are 0.0 to 0.5mmol/L follow advice in section A.
  • If ketones are 0.6 to 1.4mmol/L and blood glucose is more than 8.0mmol/L, follow advice in section B.
  • If ketones are 1.5mmol/L or more and blood glucose is more than 8.0mmol/L, continue advice in section C.

If ketones are more than 1.5mmol/L for more than 6 hours or if your child is vomiting with high ketones or having difficulty breathing, bring them to the Emergency Department.

How to calculate your total daily dose

Total daily insulin (TDD) is all the insulin you usually have in a day. This will vary a bit depending on what you eat each day.

Check your pump history for your TDD or follow the points below to work out you total daily insulin:

Total basal insulin =
Usual insulin dose for breakfast =
Usual insulin dose for lunch =
Usual insulin dose for tea =
Usual insulin dose for supper =
Usual insulin dose for snacks =
Total daily dose =

Sick day dose table

Total daily dose Sick day dose (in addition to basal and bolus given) of quick acting insulin
  10% 20%
1 to 10 units 1 unit 2 units
11 to 15 units 1.5 units 3 units
16 to 20 units 2 units 4 units
21 to 25 units 2.5 units 5 units
26 to 30 units 3 units 6 units
31 to 35 units 3.5 units 7 units
36 to 40 units 4 units 8 units
41 to 45 units 4.5 units 9 units
46 to 50 units 5 units 10 units
51 to 55 units 5.5 units 11 units
56 to 60 units 6 units 12 units
61 to 65 units 6.5 units 13 units
66 to 70 units 7 units 14 units
71 to 75 units 7.5 units 15 units
76 to 80 units 8 units 16 units
81 to 85 units 8.5 units 17 units
86 to 90 units 9 units 18 units
91 to 95 units 9.5 units 19 units
96 to 100 units 10 units 20 units

Sick day rules monitoring chart

Date and time Blood glucose (mmol/L) Ketones (mmol/L) Food Insulin dose (units) Pump or pen injection

Activating sick day rules profiles on T-Slim

  1. Click ‘Options’
    Click options on T Slim
  2. Click ‘My Pump’
    Click My Pump
  3. Click ‘Personal Profiles’
    Click Personal Profiles - the top option
  4. Click ‘Sick 130’
    Click Sick 130 - the third option down
  5. Click ‘Activate’
    Click Activate - the second option down
  6. Click the ‘Blue Tick’
    Click the blue tick - the right hand option
  7. Follow the same process to revert to profile 1 or SICK 150
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Disclaimer

Please note: this is a generic information sheet relating to care at Sheffield Children’s NHS FT. These details may not reflect treatment at other hospitals. This information is not intended as a substitute for professional medical care. Always follow your healthcare professionals’ instructions. If this resource relates to medicines, please read it alongside the medicine manufacturer’s patient information leaflet. If this information has been translated into another language from English, efforts have been made to maintain accuracy, but there may still be some translation errors. If you are unsure about any of the guidance in this resource or have specific questions about how it relates to your child, always ask your healthcare professional for further advice.

Resource number: DIA10

Resource Type: Article

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United Kingdom

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