T/F: Concurrent disease is documented in the majority of canine AND feline cases of DKA?
*70% of dogs and 90% of cats have concurrent diseases when presenting with DKA
What are the 2 main mechanisms of DKA occurence?
Lack of insulin
Increased counter-regulatory hormones
In patients with DKA, what are the common concurrent diseases?
Infections (esp UTI)
An 8 year old Miniature Schnauzer presents for PU/PD, not eating, vomiting, weight loss, and confusion.
Exam: 10% dehydrated, BCS 3/9, weak, altered mentation, Temp 99.1F. Painful on palpation of the cranial abdomen.
You suspect DKA. What do you expect to find on the urinalysis?
*Dipstick only measures acetoacetate. Ketones in DKA are predominantly B-hydroxybuterate.
Is testing the ketone levels using plasma or urine more specific?
*plasma is more sensitive
In a patient with DKA, what are the 2 most important treatments, before doing anything else?
Intense fluid therapy
How will you initiate fluid therapy for a DKA patient?
Replace fluid deficit over first 24 hours (20% in first hour, 30% in next 5 hours, 50% in next 18 hours)
What treatment is given for hypophosphatemia?
KPO4 added to 0.9% NaCl
*Phosphate levels shift in parallel with Potassium. If potassium is low, phosphate is also likely low.
In some cases, Magnesium is low in DKA patients. What is the treatment?
Now that the patient is on IVF and potassium levels are under control, we're ready to start insulin! You set up a soluble insulin CRI at 1.1U/kg/day in order to decrease the serum glucose at a maximum rate of _______.
*Do it slow AF to avoid fluid rushing to the brain and causing increased ICP and brain bleed.
How often should we be checkin BG levels and adjusting the insulin CRI?
Every 1-2 hours
Your patient is now hydrated and eating on his own. What should we do with the insulin CRI?
Discontinue and switch to a longer acting insulin
(Caninsulin, Prozinc, Glargine)
At what pH would we administer HCO3 in dextrose saline?
If the pH drops below 7 after starting IVF
You are about to place an esophagostomy tube in a DKA cat who isn't eating. Where do you want the end of the tube to sit?
Around the 10th or 11th rib space.
Should not be in the stomach!
To avoid refeeding syndrome, how should we reintroduce food to these patients?
25% RER on day 1
50% RER on day 2
75% RER on day 3
100% RER on day 4
T/F: Cats get better quicker in the hospital than dogs, and have a lower rate of recurrence.
Cats do get better faster (5 days vs 6), but they have a 40% recurrence rate (likely due to concurrent pancreatitis) while dogs only have a 7% recurrence rate.
T/F: The degree of base deficit is associated with outcome in DKA dogs.
A patient presents with severe hyperglycemia and dehydration, but you don't find any ketones in the urine. What is this patient likely suffering from?
Hyperglycemic Hyperosmolar Syndrome (HHS)
Why can't you drop the BG level too fast in HHS patients?
Formation of idiogenic osmoles in the brain. If the body becomes hypo-osmolar, fluid will rush to the brain and cause cerebral edema and increased ICP.
How can you tell the difference between DKA and HHS?
Lack of ketones in HHS
HHS can also cause focal or generalized seizures and transient hemiplegia.
In HHS serum potassium levels are usually normal!
How do you begin treatment on a patient with HHS?
Isotonic fluids at high rates
After a few hours check Na+
Your HHS patient has been on IVF for 3 hours. You check a Na+ level, which is 145mEq/L. What is the next step?
Switch to 0.45% saline
*If Na+ is still less than 135mEq/L, continue isotonic fluids at 250-500mL/hr.
At what point should dextrose be added to the treatment regimen in the HHS patient?
Once the BG level reaches 250-300mg/dL
You start insulin with a 0.1U/kg bolus, followed by a CRI at 0.1U/kg/hr for the first 4-6 hours. What is the target plasma glucose level in this patient?
*Once glu reaches 300, reduce insulin to basal levels
(1-2U/hr) until patient is able to eat.