DKA pt 2

Question 1

rapid acting insulins

Answer 1

insulin lispro, aspart or glulisine

Question 2

is glucose monitoring important during insulin admin for DKA?
- frequency?
- methods

Answer 2

n Essential during insulin administration
n Frequent blood glucose - q 1 - 2 hours initially
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1. Sampling catheter (jugular catheter)
2. Interstitial Glucose Monitor
> eliminates multiple venipunctures

Question 3

do we want to give long acting or short acting insulin for DKA? why? what is our ultimate goal here and what else do we want to do to help achieve it?

Answer 3

• want to use short acting insulin
  > allows us to give more insulin, as we can give it every time blood glucose starts to rise vs long-acting which can leave us more uncertain
• also should give dextrose once blood glucose is is normal range, so that we can give even more insulin

Question 4

how to use insulin drop for DKA

Answer 4

• Regular insulin CRI - 0.1 U/kg/hr diluted in 10 mls of 0.9% NaCl
• monitor blood glucose > as our BG is highest, our insulin infusion rate is high and we do not supplement dextrose
• as our blood glucose becomes low, our insulin infusion rate is lower and we can supplement dextrose
• if we get hypoglycemic, stop insulin drop for a minute and continue fluids plus dextrose
  ie. titrate it according to patients BG

Question 5

DKA therapy biggest mistake

Answer 5

Biggest Mistake
n Aiming for ideal blood glucose at the expense of insulin administration

Question 6

alternative DKA insulin strategies occasionally used in cats

Answer 6

n CATS -provide ‘basal’ insulin
> Glargine IM +/- SC effective
> Basal Glargine SC + intermittent regular insulin
> Positive outcome & simplicity

Question 7

alternative DKA insulin strategies occasionally used in dogs

Answer 7

• Rapid acting alternative insulins as CRIs
  (If Regular insulin were to disappear from the market)
  > Lispro insulin - 0.09 U/kg/hr, titrated - Sears 2012
  > Aspart insulin - 0.09 U/kg/hr, titrated - Walsh 2016

Question 8

DKA - electrolyte and acid base deramgements related to insulin therapy

Answer 8

n Baseline values needed at presentation
n Insulin DRIVES potassium & phosphorus into cells
n Anticipate
> Potassium
> Phosphorus
> Magnesium
> Hypo-, normo-, or hypernatremia

Question 9

potassium supplementation in DKA therapy - necessary? when?
- what do we want potassium levels to be before we start insulin therapy?

Answer 9

n Hypokalemia is anticipated within 2 - 4 hours of initiating insulin therapy
n Vigilant monitoring & proactive supplementation is necessary
n want levels to be >3.2 before we start insulin therapy

Question 10

when do we expect phosphorus to lower with DKA / insulin therapy?
complications related to this?
how to supplement?

Answer 10

Hypophosphatemia anticipated within 12 - 24 hours of initiating insulin therapy
n Severe hypophosphatemia (< 0.5 mmol/L) can cause RBC hemolysis
n Supplementation: NaPO4 or KPO4
> KPO4 administration > decrease KCl administration accordingly
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Phosphorus dose:
n 0.03-0.12 mmol/kg/hr
n Typically 0.04-0.06 mmol/kg/hr for 12 hours achieves normalization of phosphorus during insulin administration
n Caution in patients with renal disease
n Once the patient is rehydrated, KCl & KPO4 can be combined

Question 11

when do we give bicarbonate supplementation for DKA?

Answer 11

n Generally avoided
n Acidosis management
> IV fluid & insulin administration usually addresses severe acidosis appropriately
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If acidosis persists after fluid resuscitation
n pH < 6.9, Bicarbonate < 12 OR tCO2 < 12
n Conservative bicarbonate supplementation delivered slowly (over 6 hours)

Question 12

DKA antiemetics that can be used

Answer 12

n Maropitant, Metoclopramide, Ondansetron

Question 13

when might we give antibiotics in a DKA case?

Answer 13

If urinalysis is suggestive of urinary tract infection, a first line antibiotic e.g. ampicillin is recommended pending results of urine culture & sensitivity

Question 14

how to feed a DKA patient if they are not eating? when?

Answer 14

Feeding once emesis controlled
n Nasoesophageal, nasogastric, esophagostomy tube

Question 15

what monitoring is required for

Answer 15

n 24-hour care
n Blood glucose
> q 2 hours
> q 4-6 h once stable
n Vitals q 6-12 h
n PCV, TS q 12 - 24 h
n Electrolytes
> K+ q 4 hours until stable, then q 12 h
> Phos q 24 until stable
n Ketone monitoring q 12 – 24 h
> Urine dipstick
> +/- ß-hydroxybutyrate

Question 16

goals for DKA therapy

Answer 16

n Blood glucose between 7-14 mmol/L
n Resumption of Appetite
n No vomiting
n Resolution of acidosis
n Resolution of ketonuria

Question 17

when administering DKA therapy, what are our expectations? when might we see corrections of hyperglycemia and ketosis? how long does all this take? how long for hospitalization

Answer 17

In general,
n Hyperglycemia is corrected within 12 hours
n Ketosis may take 48 to 72 hours to resolve
n Average hospitalization: 5 days

Question 18

DKA prognosis - survival, recurrence

Answer 18

n Depends on underlying disease process
n Survival to discharge ~70%
n Recurrence rate:
> Dogs : at least 7%
> Cats : up to 40%

Question 19

for DKA therapy - when to switch to long-acting insulin?

Answer 19

When the patient is EATING!

Question 20

complicated DKA is called what?

Answer 20

Hyperosmolar syndrome

Question 21

how do we diagnose hyperosmolar syndrome?

Answer 21

Diagnosis: increased serum osmolality > 350 mOsm/L
n Normal 290-310 mOsm/L
n Osmolality = 2(Na+ + K+) + glucose + BUN
> Hypernatremia + Hyperglycemia +/- Azotemia

Question 22

hyperosmolar syndome clinical signs

Answer 22

Mental depression, coma

Question 23

Hyperosmolar Syndrome therapeutic considerations

Answer 23

n Slow glucose reduction
n Maintain BG > 14 mmol/L for 1st 24 hours
> To avoid cerebral edema while rehydrating the patient