DKA

Question 1

T/F: Concurrent disease is documented in the majority of canine AND feline cases of DKA?

Answer 1

TRUE

*70% of dogs and 90% of cats have concurrent diseases when presenting with DKA

Question 2

What are the 2 main mechanisms of DKA occurence?

Answer 2

Lack of insulin

Increased counter-regulatory hormones

Question 3

In patients with DKA, what are the common concurrent diseases?

Answer 3

Hepatic Lipdosis

CKD
Pancreatitis

HAC

Infections (esp UTI)

Neoplasia

Question 4

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?

Answer 4

+ Glucose

+ Ketones

*Dipstick only measures acetoacetate. Ketones in DKA are predominantly B-hydroxybuterate.

Question 5

Is testing the ketone levels using plasma or urine more specific?

Answer 5

Urine

*plasma is more sensitive

Question 6

In a patient with DKA, what are the 2 most important treatments, before doing anything else?

Answer 6

Intense fluid therapy

Potassium replacement

Question 7

How will you initiate fluid therapy for a DKA patient?

Answer 7

Isotonic fluids

1.5-2x maintenance

Replace fluid deficit over first 24 hours (20% in first hour, 30% in next 5 hours, 50% in next 18 hours)

MONITOR!

Question 8

What treatment is given for hypophosphatemia?

Answer 8

KPO4 added to 0.9% NaCl

*Phosphate levels shift in parallel with Potassium. If potassium is low, phosphate is also likely low.

Question 9

In some cases, Magnesium is low in DKA patients. What is the treatment?

Answer 9

MgSO4 CRI

Question 10

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 _______.

Answer 10

54-72mg/dL/hr (3-4mmol/hr)

*Do it slow AF to avoid fluid rushing to the brain and causing increased ICP and brain bleed.

Question 11

How often should we be checkin BG levels and adjusting the insulin CRI?

Answer 11

Every 1-2 hours

Question 12

Your patient is now hydrated and eating on his own. What should we do with the insulin CRI?

Answer 12

Discontinue and switch to a longer acting insulin

(Caninsulin, Prozinc, Glargine)

Question 13

At what pH would we administer HCO3 in dextrose saline?

Answer 13

If the pH drops below 7 after starting IVF

Question 14

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?

Answer 14

Around the 10th or 11th rib space.

Should not be in the stomach!

Question 15

To avoid refeeding syndrome, how should we reintroduce food to these patients?

Answer 15

25% RER on day 1

50% RER on day 2

75% RER on day 3

100% RER on day 4

Question 16

T/F: Cats get better quicker in the hospital than dogs, and have a lower rate of recurrence.

Answer 16

FALSE

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.

Question 17

T/F: The degree of base deficit is associated with outcome in DKA dogs.

Answer 17

TRUE

Question 18

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?

Answer 18

Hyperglycemic Hyperosmolar Syndrome (HHS)

Question 19

Why can’t you drop the BG level too fast in HHS patients?

Answer 19

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.

Question 20

How can you tell the difference between DKA and HHS?

Answer 20

Lack of ketones in HHS

HHS can also cause focal or generalized seizures and transient hemiplegia.

In HHS serum potassium levels are usually normal!

Question 21

How do you begin treatment on a patient with HHS?

Answer 21

Isotonic fluids at high rates

After a few hours check Na+

Question 22

Your HHS patient has been on IVF for 3 hours. You check a Na+ level, which is 145mEq/L. What is the next step?

Answer 22

Switch to 0.45% saline

*If Na+ is still less than 135mEq/L, continue isotonic fluids at 250-500mL/hr.

Question 23

At what point should dextrose be added to the treatment regimen in the HHS patient?

Answer 23

Once the BG level reaches 250-300mg/dL

Question 24

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?

Answer 24

250-300mg/dL

*Once glu reaches 300, reduce insulin to basal levels

(1-2U/hr) until patient is able to eat.