Diabetic Ketoacidosis

Dr. Aimee Jalkanen

What is Diabetic Ketoacidosis (DKA)?

Life-threatening metabolic condition Result of insulin deficiency and resistance Excessive production of ketoacids by the liver Leads to metabolic acidosis, hyperosmolality,

electrolyte imbalances, systemic illness

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

Etiology and Pathophysiology

Shift in hepatic metabolism from fat synthesis to fat oxidation and ketogenesis produces ketone bodies (acetoacetic acid, β-hydroxybutyric acid, acetone)

Insulin deficiency and resistance leads to increased production of ketones

Lipolysis increases, thus more FFAs are available for the liver to produce ketones

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

Etiology and Pathophysiology

Accumulation of ketones overwhelms the body’s buffering system leading to metabolic acidosis

Renal tubules are unable to have complete resorption leading to ketonuria

Osmotic diuresis ensues leading to increased loss of Na+, K+ in urine

Loss of electrolytes and fluid through urine and vomiting leads to azotemia, cellular dehydration

Common Signalment

Older dogs (7-9) and cats (9-11)

Female dogs 2x > males Male cats > females Multiple dog breeds

commonly affected include: Schnauzer, Poodle, Bichon Frise, Keeshond

Cats: no breed disposition

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Pertinent History

May or may not be a previously diagnosed diabetic

Have shown signs of diabetes including PU/PD, weight loss despite increased appetite

Recent history includes vomiting, weakness, anorexia

Physical Exam Findings

Dehydration-often moderate to severe

Weakness Respiratory pattern changes:

tachypnea or Kussmaul’s 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)

Diagnostics

Complete blood count Biochemical profile Electrolyte panel Urinalysis and culture Radiographs, ultrasound, and further

diagnostics may be needed

Results

CBC– Variable, may show high white blood cells

Profile– High blood glucose, low sodium, low potassium– High cholesterol– Liver enzyme elevation– Azotemia

Urinalysis– Positive ketones– Glucosuria– Pyuria and bacteria common if concurrent UTI

cPL positive if concurrent pancreatitis

Treatment-Fluid Therapy

Crystalloid, type based on electrolytes Supplement with potassium

– Usually 30-40 mEq/L Supplement phosphorus if <1.5mg/dL

– Necessary to avoid hemolytic anemia Add 2.5-5% dextrose to fluids once BG

approaches 250 mg/dL

Treatment-Insulin

Begin after starting fluid therapy Intermittent IM technique:

– 0.2 U/kg IM initially– Then, 0.1 U/kg IM hourly

Insulin CRI– 0.05 U/kg/h (cat) 0.1 U/kg/h

(dog) in 0.9% NaCl Adjustments made based on

BG– Switch to every 0.1 U/kg 6 to 8

h SQ once BG ~ 250 mg/dL Goal is to slowly decrease BG

until between 100-300 mg/dL

Treatment-Other

Bicarbonate supplementation– Use with caution– Supplement if bicarb is < 12mEq/L– HCO3

- = body weight (kg) x 0.4 x (12 - patient’s HCO3-) x 0.5

– Add to fluids and given over 6 h Anti-emetics if needed to control vomiting Nutrition: Very important to encourage patient’s to

eat to avoid hypoglycemia Antibiotics: Many patients have concurrent UTIs

Monitoring

Frequent blood glucoses– Initially every 1 to 2 hours– May begin to decrease when BGs stabilize

Hydration status– Monitor inputs (fluids) and outputs (urine, vomit, diarrhea)– Make adjustments as needed

Electrolyte concentrations– Adjust fluids and additives as necessary

Patient’s weight, temperature, blood pressure

Potential complications

Goal is to correct blood glucose, acidosis, and electrolyte abnormalities SLOWLY (24-48 hours)

Hypokalemia, hypoglycemia, hypernatremia, hemolytic anemia commonly occur

Neurologic signs related to cerebral edema

Long-term Care and Follow-up

Treat concurrent diseases– Urinary tract infections– Diarrhea– Pancreatitis– Cushing’s disease

Establish good control over blood glucose levels

– Regular check-ups– Blood glucose curves to help

establish insulin dose free-glucose-meter.com

Long-term Care and Follow-up

Dietary changes– Controlled weight loss– High fiber, low calorie, low-fat

diets– Hill’s w/d, r/d, or m/d, Purina’s

OM or DM, other senior or weight loss diets

– Avoid giving treats or snacks high in fat and sugar

Encourage regular exercisefindavet.us

At home care and monitoring

Owners of diabetics need to be aware of DKA and its life-threatening nature

Have owners contact a veterinarian if:– Patient is vomiting or having diarrhea– Stops eating– Becomes lethargic– Urine and/or breath smells “funny”

DKA on ER

May be a stat triage-many of these patients are very ill

Brief history from owner-if known diabetic, ask about insulin, when and how much last given and has patient been eating

Ask permission for IV catheter, diagnostics (about $150 to $200 to start)

Once in treatment room

Obtain blood for CBC/profile and a urine sample

Run an I-stat 8– Glucose, pH, electrolytes

Check urine dipstick– Look for ketonuria (if

negative, does NOT rule out DKA)

Place IV catheter Prepare fluids

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Sources

Côté, Etienne (ed): Clinical Veterinary Advisor. St. Louis, Mosby, Inc. 2007.

Hill’s Key to Clinical Nutrition 2007-2008.

Thanks for your attention!