Diabetic KetoacidosisDr. Aimee Jalkanen

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What is Diabetic Ketoacidosis (DKA)?Life-threatening metabolic conditionResult of insulin deficiency and resistanceExcessive production of ketoacids by the liverLeads to metabolic acidosis, hyperosmolality, electrolyte imbalances, systemic illness

http://petdiabetes.wikia.com/wiki/Ketoacidosis

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Etiology and PathophysiologyShift in hepatic metabolism from fat synthesis to fat oxidation and ketogenesis produces ketone bodies (acetoacetic acid, -hydroxybutyric acid, acetone)Insulin deficiency and resistance leads to increased production of ketonesLipolysis increases, thus more FFAs are available for the liver to produce ketones

http://petdiabetes.wikia.com/wiki/Ketoacidosis

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Etiology and Pathophysiology Accumulation of ketones overwhelms the bodys buffering system leading to metabolic acidosisRenal tubules are unable to have complete resorption leading to ketonuriaOsmotic diuresis ensues leading to increased loss of Na+, K+ in urineLoss of electrolytes and fluid through urine and vomiting leads to azotemia, cellular dehydration

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Common SignalmentOlder dogs (7-9) and cats (9-11)Female dogs 2x > malesMale cats > femalesMultiple dog breeds commonly affected include: Schnauzer, Poodle, Bichon Frise, KeeshondCats: no breed disposition

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Pertinent HistoryMay or may not be a previously diagnosed diabeticHave shown signs of diabetes including PU/PD, weight loss despite increased appetiteRecent history includes vomiting, weakness, anorexia

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Physical Exam FindingsDehydration-often moderate to severeWeaknessRespiratory pattern changes: tachypnea or Kussmauls respiration (slow, deep breathing)Abdominal pain (associated with pancreatitis)Strong acetone odor to breath (sweet smell)Cataracts (more common in dogs)Diabetic neuropathy (dropped hocks, more common in cats)

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DiagnosticsComplete blood countBiochemical profileElectrolyte panelUrinalysis and cultureRadiographs, ultrasound, and further diagnostics may be needed

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ResultsCBC

Variable, may show high white blood cells Profile

High blood glucose, low sodium, low potassiumHigh cholesterolLiver enzyme elevationAzotemiaUrinalysis

Positive ketonesGlucosuriaPyuria and bacteria common if concurrent UTIcPL positive if concurrent pancreatitis

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Treatment-Fluid TherapyCrystalloid, type based on electrolytesSupplement with potassium

Usually 30-40 mEq/LSupplement phosphorus if

Treatment-InsulinBegin after starting fluid therapyIntermittent IM technique:

0.2 U/kg IM initiallyThen, 0.1 U/kg IM hourlyInsulin CRI

0.05 U/kg/h (cat) 0.1 U/kg/h (dog) in 0.9% NaClAdjustments made based on BG

Switch to every 0.1 U/kg 6 to 8 h SQ once BG ~ 250 mg/dLGoal is to slowly decrease BG until between 100-300 mg/dL

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Treatment-OtherBicarbonate supplementation

Use with cautionSupplement if bicarb is < 12mEq/LHCO3- = body weight (kg) x 0.4 x (12 - patients HCO3-) x 0.5Add to fluids and given over 6 hAnti-emetics if needed to control vomitingNutrition: Very important to encourage patients to eat to avoid hypoglycemiaAntibiotics: Many patients have concurrent UTIs

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MonitoringFrequent blood glucoses

Initially every 1 to 2 hoursMay begin to decrease when BGs stabilizeHydration status

Monitor inputs (fluids) and outputs (urine, vomit, diarrhea)Make adjustments as neededElectrolyte concentrations

Adjust fluids and additives as necessaryPatients weight, temperature, blood pressure

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Potential complicationsGoal is to correct blood glucose, acidosis, and electrolyte abnormalities SLOWLY (24-48 hours)Hypokalemia, hypoglycemia, hypernatremia, hemolytic anemia commonly occurNeurologic signs related to cerebral edema

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Long-term Care and Follow-upTreat concurrent diseases

Urinary tract infectionsDiarrheaPancreatitisCushings diseaseEstablish good control over blood glucose levels

Regular check-upsBlood glucose curves to help establish insulin dosefree-glucose-meter.com

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Long-term Care and Follow-upDietary changes

Controlled weight lossHigh fiber, low calorie, low-fat dietsHills w/d, r/d, or m/d, Purinas OM or DM, other senior or weight loss dietsAvoid giving treats or snacks high in fat and sugarEncourage regular exercise

findavet.us

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At home care and monitoringOwners of diabetics need to be aware of DKA and its life-threatening natureHave owners contact a veterinarian if:

Patient is vomiting or having diarrheaStops eatingBecomes lethargicUrine and/or breath smells funny

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DKA on ERMay be a stat triage-many of these patients are very illBrief history from owner-if known diabetic, ask about insulin, when and how much last given and has patient been eatingAsk permission for IV catheter, diagnostics (about $150 to $200 to start)

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Once in treatment roomObtain blood for CBC/profile and a urine sampleRun an I-stat 8

Glucose, pH, electrolytesCheck urine dipstick

Look for ketonuria (if negative, does NOT rule out DKA)Place IV catheterPrepare fluids

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SourcesCt, Etienne (ed): Clinical Veterinary Advisor. St. Louis, Mosby, Inc. 2007.Hills Key to Clinical Nutrition 2007-2008.

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Thanks for your attention!

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