DKA

Question 1

DKA definition

Answer 1

n Life threatening complication of uncontrolled
diabetes mellitus
n Sequela of insulin deficiency

Question 2

Hallmark diagnosis of DKA

Answer 2

1. Hyperglycemia
2. Glucosuria
3. Ketonuria
4. +/- Metabolic acidosis

Question 3

4 conditions ass’d with ketone production:

Answer 3

1. Insulin deficiency
2. Starvation
3. Dehydration
4. Diabetogenic Hormone Excess
   n Glucagon, Epinephrine, Norepinephrine, Cortisol, Growth Hormone

Question 4

Diabetic Ketoacidosis - what is it? which ketones are present?

Answer 4

n Cellular starvation in the face of hyperglycemia
n Ketones - alternate energy source
1. Acetone
2. Acetoacetate
3. ß-hydroxybutyrate

Question 5

what are ketones? what conditions / clinical signs do they contribute to?

Answer 5

Organic acids
n Alternate energy source
> Short term
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Contribute to:
n Acidosis
n Nausea
n Feeling terrible
n Diuresis
n Dehydration

Question 6

DKA Patients usually fall into what categories?

Answer 6

n Newly diagnosed diabetics
n Known diabetics with an often precipitating underlying cause

Question 7

DKA Patients can sometimes be known diabetics with an often precipitating underlying cause
- what are precipitating underlying causes for dogs?

Answer 7

n Urinary tract infection
n New endocrinopathy
n Acute pancreatitis

Question 8

DKA Patients can sometimes be known diabetics with an often precipitating underlying cause
- what are precipitating underlying causes for cats?

Answer 8

n Acute pancreatitis
n Hepatic lipidosis
n Chronic inflammatory disease
n Bacterial or viral infections
n Chronic kidney disease
n Neoplasia

Question 9

Non-specific changes we may see in a DKA patient on general PE

Answer 9

n Dehydration
n Weakness
n Tachypnea
n Kussmaul breathing
> Slow deep breathing due to severe metabolic acidosis
n Acetone breath
n Abdominal pain
n Hepatomegaly
n Muscle wasting

Question 10

DKA diagnostics - CBC results for dogs and cats

Answer 10

~ 50% of dogs with DKA have:
n Non regenerative anemia
n Neutrophilia with left shift
n Thrombocytosis
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Cats with DKA have&raquo_space;
n Heinz bodies
n Correlated with plasma β-Hydroxybutyrate

Question 11

DKA diagnostics - what do we see on biochem?

Answer 11

Typical findings:
- increased glucose (persistent/repeatable)
- decreased tCO2 (reflective of a low bicarbonate)
- increased Urea / creatinine
- increased (mild) ALT, ALP, AST
- increased Amylase & lipase

Question 12

DKA diagnostics - urinalysis results

Answer 12

Urinalysis or Urine Dip Stick
n Glucosuria
n Ketonuria
n Bacteuria

Question 13

how can we detect ketonemia / ketonuria? what exactly do they tell us?

Answer 13

n Urine reagent strips n Urine or Serum
n Detect acetoacetic acid & acetone
n Do NOT detect ß-hydroxybutyrate
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Acetoacetic acid can change into acetone or ß-hydroxybutyrate
> ß-hydroxybutyrate can change back to acetoacetic acid

Question 14

β-hydroxybutyrate βHB normal vs DKA results in cats

Answer 14

n Normal: <0.5 mmol/L
n Ill / Diabetic cats: 0.5-2.0
n Diagnostic for DKA: > 2.55

Question 15

β-hydroxybutyrate βHB normal vs DKA results in dogs

Answer 15

• Normal: < 0.15 mmol/L
• Diabetic: < 2.8
• DKA: ≥ 3.5

Question 16

DKA urine culture - when to do it? results?

Answer 16

n Bacterial culture of urine should be performed regardless of sediment
n Urinary tract infection ~ 20% of dogs
> Cause: Diabetic immunosuppression

Question 17

Most DKA patients show what clinical signs:

Answer 17

n Dehydrated
n Anorexic
n Metabolically deranged
> Electrolyte Disturbances
> Acid Base Disturbances
n Require hospitalization

Question 18

Emergency Approach to DKA patient - what 5 things do they need, broadly?

Answer 18

1. Rehydration
2. Initiating Insulin
3. Preventing & Correcting Electrolyte Disturbances
4. Managing clinical signs
5. Identifying & treating precipitating factors

Question 19

rehydration for DKA patient
- how important? purpose?

Answer 19

n KEY
n Restores circulating blood volume & tissue
perfusion
n Clears ketones
n Corrects electrolyte disturbances

Question 20

rehydration for DKA patient
- what fluids to use?
- how fast should deficits be corrected?
- what are losses? how do we deal with them?
- how much?
- how do we approach maintenance? when to start?

Answer 20

n Intravenous isotonic crystalloid solution
> Plasmalyte A, Normosol R, Lactated Ringers
> 0.9% NaCl (will exacerbate acidosis)
n Fluid deficits should be corrected within 24 hours
n Ongoing fluid losses can be large
> Frequent reassessment
> Ensure rehydration is moving according to plan
- 2x maintenance IV fluids is rarely enough!
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Maintenance Fluids
n 0.45% NaCl ideal
> Because diabetes mellitus patients have hypotonic water losses
n To start only once patient rehydrated & Na+ is within normal limits

Question 21

insulin therapy for DKA
- When to initiate?
- purpose?

Answer 21

n Deliver IV fluids for at least 1-2 hrs before initiating insulin
n Insulin:
n Drives glucose into the cells
n Cellular starvation reversed
> Ketone production abolished
> Insulin also promotes ketone metabolism
WANT TO KEEP GIVING INSULIN
GOAL - Timely resolution of ketonemia

Question 22

insulin therapy for DKA - what are our blood glucose goals for ongoing therapy? how much insulin?

Answer 22

n ONGOING Insulin therapy
n Reduce & maintain blood glucose (BG)
> BG - 5.5 - 14 mmol/L (100 to 250 g/dL)
n Add DEXTROSE (2.5-5%) to the IV fluids to allow continued insulin administration without causing hypoglycemia
n Maximizing insulin administration

Question 23

which insulin to use for DKA therapy? protocols for admin? duration of action?

Answer 23

SHORT ACTING REGULAR INSULIN
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Regular (Toronto) Insulin
n Most widely used insulin
n Protocols
> IM / SC administration
> Intravenous Sliding Scale Infusion
n Duration of action of regular insulin
> IM 2-4 hours
> SC 4-6 hours
> IV administration - minutes to initiate / terminate effect Short acting

Question 24

Regular Insulin
Routes of Administration – pros and cons

Answer 24

IM
n Pros: less equipment required
n Cons: repeated IM injections
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SQ
n Pros: less painful then IM
n Cons: repeat injections, potential for delayed uptake
> Not appropriate in dehydrated patient
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IV
n Pros: More precise
n Cons: More technically demanding
> At least 2 IV infusions (patient fluids & insulin infusion)