ketoacidotic dog

RE: ketoacidotic dog

Rory Bell — Tue, 15 Mar 2016 00:13:45 GMT

Hi Anthony

I guess you might need to be careful not to over supplement with phosphate early on, when a dehydrated patient might have some renal compromise that could worsen if the calcium x phosphate became greater than 6 and hence predisposed to nephrocalcinosis. One rule of thumb is to deliver half the amount of potassium you initially give as KCl and half as KPO4, bearing in mind that the patient will be predisposed to developing hypokalaemia prior to a similar drop in phosphate concentrations. No idea why one would wait until a predictable event (hypophosphataemia) occurred prior to supplementation though, as severe hypophosphataemia can have consequences (haemolytic anaemia)

All the best

RE: ketoacidotic dog

Anthony Dennison — Mon, 14 Mar 2016 10:46:30 GMT

[quote user="Rory Bell"]2) Rehydration is obviously important. As glucose moves intracellularly, and as the remaining ketones are lost in the urine, so too will potassium concentrations drop. Its a good idea to start supplementing potassium in your IVFT because in about 12-24hrs time, without it, most severely ketoacidotic dogs who remain inappetent will become severely hypokalemic. Phosphate concentrations will also start to fall, usually 12-24hrs after potassium starts to drop, so it's probably sensible to start phosphate supplementation (e.g. 50% of your potassium as KCL and 50% as KPO4, providing the dog isn't hyperphosphatemic, for example, because it's kidneys are packing it in). Pharmacist may be able to help with potassium phosphate as well. Don't put phosphate into calcium containing solutions - use 0.9% NaCL. Monitor electrolyte concentrations q12hrs if possible[/quote]

I remember being told at university not to rush into supplementing phosphate in DKA cases, only if they end up severely low. Can't remember why though.

RE: ketoacidotic dog

Andrew Mellor — Mon, 07 Mar 2016 09:22:13 GMT

thank you so much for all the replies but especially for the comprehensive one from Rory.

alarm bells definitely rang when I saw this one and doubt that this dog has a great future but for now is hugely improved

RE: ketoacidotic dog

Rory Bell — Sat, 05 Mar 2016 16:39:40 GMT

Hi John and Ruths

I've used both CRI's and intermittent administration of neutral insulin, and would usually tend more towards the former route, for the reasons you've both described. There is however no clinical evidence to suggest CRIs are 'better' in terms of outcome, and depending on the equipment and staffing available, intermittent injections may be a better way of ensuring the requisite dose of insulin is delivered to the patient. For someone looking for advice on how to manage a DKA, I'm very wary therefore of saying that CRI's are in any way the 'standard of care'.

Cheers

RE: ketoacidotic dog

ruths — Sat, 05 Mar 2016 14:12:50 GMT

[quote user="John Ellis"]

Hi,

Sorry to slightly hijack this, but a question for Rory - is there any reason you would use intermittent IM over CRI? I always use neutral insulin for initial treatment, but I tend to use CRI's over intermittent IM. Just wondered.

Many thanks

John

[/quote]

i would certainly vote for CRI. I Feel like I can dial the insulin up or down so much easier.

and slightly less jabbing for the dog.

Challenging case

RE: ketoacidotic dog

John Ellis — Sat, 05 Mar 2016 14:07:42 GMT

Hi,

Many thanks

John

RE: ketoacidotic dog

Rory Bell — Sat, 05 Mar 2016 13:29:21 GMT

I agree Wynne, and the owners will need the necessary finances and commitment to care for this dog hereafter.

One other thing i forgot to mention regarding intravenous fluid therapy; this dog, like any poorly controlled diabetic, will have an osmotic duiresis. He will be losing much more fluid than normal, and fluid rates will have to be adjusted accordingly ('maintenance' rates for this dog will be much higher than 2.5ml/kg/hr).

RE: ketoacidotic dog

Hannah Wynne Richards — Sat, 05 Mar 2016 12:57:07 GMT

Where alarm bells would start ringing for me is the combination of "formerly eligible for PDSA" and keto-acidosis.

Was it keto-acidotic because the owners had been putting off bringing it in?

Wynne

RE: ketoacidotic dog

Rory Bell — Sat, 05 Mar 2016 12:05:17 GMT

Three things to attend to:

1) switching off ketone production

2) hydration, and actual or incipient electrolyte imbalances

3) underling diseases

1) If the dog is dehydrated / hypovolemic, absorption of insulin from a s/c depot injection will be erratic at best. Probably better in the initial stages to use neutral / regular insulin (available from any pharmacist) at a dose of 0.2iu/kg i/m. Monitor BG hourly and repeat dosing in increments of 0.1iu/kg until BG is in the mid teens. At that stage, you can either switch to s/c administration q 4 hours with associated monitoring of BG, or, if the dog is eating ok and very much brighter, go with caninsulin (or whatever intermediate acting insulin you have) q 12hrs. If the dog is not eating or otherwise unstable, short acting insulins allow a safer way of controlling ketone production without the risks of hypoglycaemia that intermediate acting insulins. Not that we are only focusing on controlling ketone production here, I've said nothing about glycemic control. You're not going to be able to achieve proper glycemic control for a good week or two yet, and it's pointless (and potentially dangerous) to attempt this with the dog in its present condition. Dropping the BG into the mid teems is a surrogate marker for shifting the metabolism away from ketone production. Its the ketones, and not the high BG that are potentially lethal in most situations.

2) Rehydration is obviously important. As glucose moves intracellularly, and as the remaining ketones are lost in the urine, so too will potassium concentrations drop. Its a good idea to start supplementing potassium in your IVFT because in about 12-24hrs time, without it, most severely ketoacidotic dogs who remain inappetent will become severely hypokalemic. Phosphate concentrations will also start to fall, usually 12-24hrs after potassium starts to drop, so it's probably sensible to start phosphate supplementation (e.g. 50% of your potassium as KCL and 50% as KPO4, providing the dog isn't hyperphosphatemic, for example, because it's kidneys are packing it in). Pharmacist may be able to help with potassium phosphate as well. Don't put phosphate into calcium containing solutions - use 0.9% NaCL. Monitor electrolyte concentrations q12hrs if possible

3) Most DKA dogs will have developed some other disease that has pushed their diabetes 'over the edge' and precipitated this crisis. Depending on the clients finances, looking for other systemic diseases, including pancreatitis and bacterial infections (esp UTI - pyelonephritis) is a good idea. I'd certainly consider starting the dog on broad spectrum abs in the initial stages of treatment.

Hope this helps, let me know if you've any questions. There are, of course way more involved protocols in various tests, but the above is a reasonable starting point, assuming of course that the client has the necessary finances and commitment to subsequently manage a diabetic dog for the rest of its life.

RE: ketoacidotic dog

Michael Woodhouse — Sat, 05 Mar 2016 11:37:55 GMT

We've always managed them with Caninsuliun, because that is all we have. Generous IV fluids and add glucose if their blood glucose level is getting too low.

I appreciate perhaps not 'gold standard' but I will be rather surprised if your Labrador doesn't want some tea.....