SAM - DKA

When would animals present with DK?

Undiagnosed DM

Insulin resistance, leading to poorly controlled DM

When you have a decrease of insulin body needs to rely on other resources for energy. As a result, you have an increase in insulin counter regulatory hormones.

Describe how the body gets energy in this process

Lipolysis resulting in FFA

FFA converted to ketones via beta oxidation

Ketones enter crabs cycle

Excess of ketones spill in blood

List three ketones

Acetoacetate

Acetone

Beta hydroxy butyrate

How DKA cause metabolic acidosis

Ketones

Lactic acid due to hypoxia via dehydration (osmotic diuresis)

With DKA, which electrolytes are readily lost in the urine

Potassium

Phosphorus

Magnesium

What clinical signs does a patient with DKA display?

They will have DM triad signs plus the following:

G.I. - vomiting, diarrhea, anorexia

Lethargic and weak

During the physical exam, you will see that an animal with DKA is dehydration might have acetone breath, and kussmaul respiration

What is kussmaul respiration

Long inspiratory breath, hold, and then breathe out

(dog is in a meditative state)

How can you confirm your diagnosis after doing all these tests to confirm DKA

Urine dipstick will find ketones and glucose

Only detects acetoacetate and acetone

Can also use ketometer

Note: if they feel well and you see ketones in the urine does not necessarily mean they are DKAI need aggressive treatment. Look at overall signs and treat accordingly.

If you want to check beta hydroxybutyrate on urine dipstick, what can you do?

Add several drops of hydrogen peroxide to urine

List six key treatment considerations for DKA

Hydration/perfusion

Blood glucose

Electrolytes

Acid base

Nutrition

Pain

What is your first choice for fluids when treating dehydration and shock in DKA patient

Isotonic such as norm - R or plasmalyte

Acceptable = 0.9% NACL or LRS

When we correcting fluid in dogs and cats, why is cats done over a period of 12 to 24 hours whereas dogs, it can be done in 6 to 12 hours

Cats are much more susceptible to volume overload

Why would potassium or phosphorus levels look normal prior to correcting metabolic acidosis?

Cellular shift

Once corrected, they can become very low so you should always think about supplementing your fluid with potassium and or phosphorus

So provide half of the potassium you're giving as Kphos

What is a major consequence of hypophosphatemia (<1.0mg/dl)?

Haemolytic anaemia

Without phosphorus, you have a decrease in ATP and this can shut down the sodium potassium pump leading to rbc cell destruction

When do you supplement magnesium?

If blood magnesium below 0.7 meq/L

Usually requires dedicated IV catheter

What are the risks of giving sodium bicarbonate IV?

Osmotic shifts

Paradoxical CNS acidosis

Indications:

Bicarb less than 12 MG/DL

Blood pH less than 7.1

Anion gap >30

Doing DKA when do you start insulin administration?

First have them partially rehydrated

Make sure potassium is not less than 2.5 (insulin drives cellular shift)

Which type of insulin do you use for DKA?

Regular

Intermittent IM or CRI IV

How often are you monitoring glucose level?

Every hour until less than 250MG/DL, then 2 to 6 hours

How often are you monitoring potassium phosphorus

2 to 4 hours for the first 24 hours

How often are you checking respiratory rate

Every One to two hours (can indicate volume overload)

Bodyweight can also tell you about volume overload

When do you see ketones decrease

Usually on day, two

Check every 12 hours

Explain, hyperosmolar syndrome or hyper osmolar hyperglycaemic state

Body has severe hyperglycaemia (600-1600 mg)

This pulls water into the urine, causing severe dehydration

Blood osmolality increases leading to water, leaving the cells, causing cellular dehydration especially in the brain

Ultimately, you will get neurologic signs

While glucose goes up sodium decreases

This can occur with or without DKA

Usually due to poorly controlled DM

Comorbidities are common

How to treat hyper osmolar syndrome

Same as DKA but correct hyperglycaemia more slowly

Fluid choice 0.9% NACL

Insulin not started until intravascular volume is normal

What is the dosage of insulin when treating hyper osmolar syndrome?

Half of that used for DKA

Goal is to decrease glucose less than sign 50 MG/DL/H