The patient, aged 69 years, had a 43-year history of type 1 diabetes. She was on an insulin pump for the past 15 years. The patient managed her insulin pump with assistance from her husband.
Her total basal insulin on her pump was 20 units in 24 hours.
The patient was scheduled to undergo a chest wall resection with multiple planned trips to the operating room. Her stay was complicated with multiple hyperbaric treatments to the wound, steroids, parenteral nutrition, and dialysis.
The patient used an insulin-to-carbohydrate ratio of one unit per 16 grams of carbohydrates consumed with all meals and snacks. Her sensitivity was set so that one unit of insulin drops her 31 points, and from another unit will drop her 45 points. Prior to admission, the patient’s A1C was 9.3%. On admission, her creatinine level was 0.7 mg/dl. The patient’s body mass index was 33.96.
The patient’s history was significant for complications and comorbidities affecting diabetes management included a coronary artery bypass graft surgery (CABG) in 2001, gastroparesis, hyperlipidemia, obesity, a history of breast cancer with radiation-induced osteomyelitis and methicillin-resistant Staphylococcus aureus (MRSA), and a history of cerebrovascular accident.
The patient had regular eye exams with no history of retinopathy. She participated in biannual dental exams. She reported eating three meals per day plus an occasional afternoon snack. If the patient had an afternoon snack, she reported that she covered it with insulin. Prior to admission, the patient reported walking and biking regularly. The patient also worked with a personal trainer.
The patient checked blood sugar two to five times per day. Her averages in the mornings ranged from 60 to 200 mg/dl; at noon they were in the 200 mg/dl range. In the evenings, the patient’s blood sugar levels ranged from 200 to 300 mg/dl. At bedtime, her levels ranged from 200 to 400 mg/dl.
Hypoglycemia occurred at night. The patient recently adjusted basal settings for overnight hours to decrease the risk of hypoglycemia. The patient reported that some times she could tell if she has a low and other times she could not.
Read the answer for Question 1.