[update]4/19 RK PMPS 142 +2.25 385 +6 542 ketones back up to 1.9 (DKA in newly diagnosed feral)

[JL and Chip]

I’ve been at the FD dance off an on for far too many years but never had to deal with DKA. I think I have a handle on it but could use a reality check.

RK is my feral who came to me as a kitten around 18 years ago. She could never be tamed and rules were I could get within 2 feet but don’t touch. She’s always been a very small cat but it seemed she’s been losing a little weight over time so was planning to catch her and run her into the vet. I assumed her mouth was a train wreck (it is) but she always came for food and seemed bright and alert, no PU/PD, no excessive hunger, just a bit skinnier, which can happen in older cats. She’s down to 4.4 lbs. now.

Anyway, late last week I knew something was wrong when she not only let me touch her, she let me pick her up. I immediately scheduled an appt so as to have her seen before the weekend, but clinic cancelled on me last minute. I couldn’t get her in anywhere else. Over the weekend she stopped eating entirely, took a dramatic turn for the worse, and given that she was lethargic and weak, she didn’t fight me so at that point I could handle her and get some data. BG was over 500, she was severely dehydrated, urine ketones moderate. I started Ondansetron, syringe feedings, subQ fluids, and “N” insulin (only thing I could get in a pinch without a prescription, though I really hesitated to do so w/out knowing the potassium level). Got her into a clinic as soon as possible and potassium was low (2.2), chloride low, white count high, some elevated liver values, diagnosis was DKA and heading into HL. She went on IV fluids with potassium supplement and was sent home when the ketones cleared, with antibiotics, mirtazapine, and a script for Lantus.

She’s nibbling a tiny bit but not eating enough, so I’m giving her anything she wants (including dry food) and supplementing with syringe feeding. I doubt I’m getting 150 percent of calories on her but I’m trying. I’ve also continued the Ondansetron, even though the vet didn’t think it was probably necessary.

First dose of 0.5u Lantus took her from around 400 down to 66 at +4 (ish) on Relion before I lost my nerve and intervened. Because it was first shot and we were still a bit early in the cycle, she isn’t eating much, and I have to be careful not to make her vomit, I erred on the side of caution.

So here are my questions:
(1) With DKA barely resolved, and with a great risk of her dropping back into it, my instinct is to stick with 0.5u for now and try to feed the curve, although technically we should be under SLGS dosing guidelines given the dry food, which would have earned her a reduction to 0.25u. Thoughts?

She bounced up over 500 today. I’m tracking her closely to see where this cycle goes, but could use a reality check. I know academically about DKA but it’s a bit different when you’re walking the actual path, especially with a feral.

(2) Vet didn’t recheck electrolytes on discharge but said we should be good as long as she’s eating. I might take her back Friday to see where we stand. Do DKA cats typically need oral supplement to keep potassium up right after DKA given that insulin drives potassium into the cells and out of the bloodstream?

(3) Is it common to see a yo-yo regarding how post-DKA cats are acting/feeling? She was brighter and more alert on discharge, then got more lethargic 12-18 hours later (perhaps from coming off the IV?), even though her BG numbers were better and I syringe fed. Vet said I could also give subQ as needed, so I’ve been doing that as well. But her attitude is up and down. She was brighter again tonight, but her BG was over 500 at the time.

Blood ketone meter will be here tomorrow. Absolutely no one has one in stock in any of the stores or pharmacies. Im going to try to get another urine ketone check tonight (aquarium gravel is my friend; there’s no way she’s going to let me out a ladle under her, even when she’s half comatose, lol).

I’m open to any and all suggestions. Thanks all! This was not on my bucket list.

@Bron and Sheba (GA)
@Wendy&Neko
@Suzanne & Darcy
Anyone else ??

(Plan to get a spreadsheet set up for her soon; haven’t been able to break away to do it yet and I’m rusty on the process, plus will have to wedge the info into my already maxed out signature )

 

[Wendy&Neko]

Oh my, feral and DKA! She landed in the right spot. Is the mouth the only cause of infection? You giving probiotics as well as antibiotics (2 hours apart). ABs may make her feel worse and not want to eat.

My attempt at answers - with thankfully no experience but reading along here. Tagging @Sienne and Gabby (GA) as another person who does have that experience.
(1) I'd maximize the calories and insulin as much as you can. We joke that if you need to feed an ice cream sundae, then just do it. The SLGS guidelines have exceptions in cases of DKA and ketones. And knowing that you know how to test and how to bring her up if you need to. I'm presuming human meter?
(2) I think I've seen some of each. Some supplemented, some not. Getting food into her will help as well as the IV fluids with potassium. I do have experience with low potassium kitties, but not as part of DKA. A recheck is an excellent idea. Her gait may be a clue, especially if stumbling.
(3) You don't know how long she's been diabetic and how used to high numbers she is. In a kitty that's been riding high, those low numbers will likely make her feel really off. My analogy is caffeine=blood sugar. You get used to lots of it and it makes you feel awful when you cut back, but eventually get used to it again.

Some people create an extra tab on an existing spreadsheet so have more than one kitty on a spreadsheet.

 

[Bandit's Mom]

@JL and Chip, let me know if you need help setting up a spreadsheet for RK.

 

[Bron and Sheba (GA)]

I’m so sorry you are going through this especially with a feral kitty…what a lucky kitty to have you.
I agree with what Wendy has said.
As far as the dose going, I would try feeding higher carb food so that you can keep the 0.5 U dose going if possible. It will be good to hear what the ketones status is. That will tell us a lot. Let her eat whatever she will at the moment but try the higher carb food to keep the BGs up a bit.
I would definitely keep the ondansetron going for now. Most DKA kitties need help in that department.

A good idea to give subQ fluids. how much are you giving.?
I am going to ask @Bandit's Mom to set up the SSfor you as you have your hands full at the moment. She should be online about now for the next several hours hopefully.

post DKA kitties can “yo-yo”. Some are great and come home and eat everything. Others hardly eat at all and others need a feeding tube. And some eat well one day and then not the next. Going off the IV fluids probably did influence how she felt the next day. That is one reason why the sub Q fluids will help.

 

[JL and Chip]

Quick flyby … @Bandit's Mom can you PM me the info you’d need to set up a new spreadsheet? I might try to add a tab to an old spreadsheet as Wendy suggested but haven’t been in them in years and one way or another will have to track down my credentials.

Thanks everyone for all of your help. I’ll be back later to answer the questions…

 

[JL and Chip]

Is the mouth the only cause of infection?

As far as I know, yes. Her teeth are the worst I’ve ever seen.

Vet was able to do a cysto and said the urine looked good so inference was no UTI. I asked if they did a full urinalysis and requested a copy of the results but all they told me was the USG. I’ll have to follow up on that.

No PLI or x-rays/ultrasound yet.

You giving probiotics as well as antibiotics (2 hours apart). ABs may make her feel worse and not want to eat.

Ooof, I hadn’t thought of that. I have Proviable — I’ll add that to the regimen. Thanks for the suggestion!

I'm presuming human meter?

Yep. I’m using my trusty old One Touch Ultra but also picked up a new Relion Premier. I’m used to my OTU but it really is quite old so want to make sure I’m getting reliable results.

Some people create an extra tab on an existing spreadsheet so have more than one kitty on a spreadsheet.

Thanks for mentioning that. Might be an easy solution.

As far as the dose going, I would try feeding higher carb food so that you can keep the 0.5 U dose going if possible. It will be good to hear what the ketones status is. That will tell us a lot.

She seems to be gravitating toward the higher carb food anyway (both dry and canned) in the little she’s eating willingly, so I’ll try to work with that and stick with the higher dose.

I’m very concerned about ketone status right now. She overshot the box earlier but I touched the strip to the urine spot on the absorbent pad that’s under the box and the strip immediately turned a reddish color — corresponding to somewhere between medium and large ketones. And she’s acting punky and refusing food. I don’t know if there’s any chemical in the gel of the underpad that would react with the ketostix, but I reset the box and hope she hits it again soon so I can verify.

@JL and Chip, let me know if you need help setting up a spreadsheet for RK.

Thanks so much! I’ll be in touch as soon as I track down the info you need (which of course I don’t know at the moment ).

A good idea to give subQ fluids. how much are you giving.?

100 ml once or twice a day, depending on hydration status. Vet said I can’t really overdo fluids subQ but RK is only 4.4lbs and we don’t really know cardiac status (although there are no signs she has problems), so I want to be careful. I’m also adding water to the canned food she has down all the time as well as what I syringe feed, which includes regular canned food, recovery food, and Hydracare.

Anything else I should be doing?

 

[Bron and Sheba (GA)]

Is she lethargic? I am concerned with the meduim to large ketones. Will she eat egg or cheese?
If she’s not eating you might have to think about a feeding tube. How much food do you think she is getting altogether at the moment?
I think 200 ml is too much Sub Q fluids a day. I don’t think I would go over 150 ml max. I don’t agree with your vet that you can’t overdo subQ fluids.
I would let the vet know about the ketone result.

 

[JL and Chip]

Is she lethargic? I am concerned with the meduim to large ketones. Will she eat egg or cheese?
If she’s not eating you might have to think about a feeding tube. How much food do you think she is getting altogether at the moment?

Yes, she’s lethargic, and I’m concerned too. I just now retested a new urine sample she left in the aquarium gravel and ketones are definitely between medium and large.

I’m giving both Ondansetron and transdermal mirtaz and, in her good moments, she will sniff and nibble on fresh canned food and dry food. Mostly she just ignores the buffet, though. She seemed interested in Parmesan cheese but ultimately wouldn’t eat it. Nibbled on a bite of pork, ignored baby food, dove into FF shrimp feast for 4-5 mouthfuls once than was done. Haven’t tried eggs yet.

I don’t know the actual volume she’s taking in on her own but it’s not much. I’m syringe feeding 10-20ml of watered down canned and recovery food multiple times a day. I just fed her 30ml, which is more than I’ve tried in one sitting, so hopefully she’ll keep that down. I’ll have to look at the calorie content of some of the food and see if I can figure out approx calories.

I’m not at all opposed to a feeding tube if needed. Charlie had three of them over the years and they saved his life. I don’t know how well RK would tolerate one—maybe ok while she’s this sick. I’m quite surprised how well she’s handled all of the poking and prodding so far.

Vet is unavailable but I’m going to try to get RK into a different clinic today. I think we need to at minimum recheck electrolytes and get her back on an IV drip. BG stayed in the 500s all of yesterday and overnight and, given the ketones, I might have bent some rules and now have her down into the lower 300s.

I’m beginning to “get “why it’s called the ketone monster. I really don’t know which way this is going to go …

 

[JL and Chip]

4/18 update:

• Blood ketones 2.3
• BG firmly stuck in the 400s
• Very weak and lethargic
• Won’t eat
• Third eyelid is creeping up
• Making soft moaning vocalizations periodically

Got her into a vet today. Potassium is still low but not catastrophic. She’s severely dehydrated again despite consistent subQ fluids at home. Liver values are more elevated than when initially hospitalized despite syringe feeding every 2-3 hours, so still a HL risk. Vet mentioned a feeding tube (which I’m all for), but said she’s not strong enough or hydrated enough to put one in just yet—so we’re working on getting her there. Also got a different antibiotic and different fluids. Might add on Denamarin for good measure. So far none of the clinics can take her in for IV fluids but I’ll make more calls tomorrow if she’s still with us. Onward we trudge. Positive vibes appreciated.

Question:
Anyone have thoughts about either reverting back to a faster-acting insulin such as “N” or perhaps adding a micro dose of “R” onto the Lantus?

 

[JL and Chip]

BG still in the 400s
Blood ketones 6.4
Planning to take her in again to get her on IV fluids.

Vet today gave me the blunt truth that he doesn’t think she’ll make it (I appreciate his honesty—he called her “a dumpster fire of medical issues” and I don’t disagree).

 

[Bandit's Mom]

Anyone have thoughts about either reverting back to a faster-acting insulin such as “N” or perhaps adding a micro dose of “R” onto the Lantus?

Going to tag @Wendy&Neko for dosing advice on using R with L insulins.

 

[Red & Rover (GA)]

or perhaps adding a micro dose of “R” onto the Lantus

@Sandy and Black Kitty

 

[Wendy&Neko]

You have used R before? Definitely an option we suggest for DKA kitties if needed. We start with a dose the same time as Lantus (L), and try to layer the R action on top of the L. We don't want it to drop her more than 100 points over the course of the R (typically 4 hours) as that could set off a bounce making things worse. So we typically start on a micro dose like 0.1 units. And have someone with experience sit with you the first time or two. There are more things to learn about when not to use R than using it. Over time we can move to mid cycle R, once we've characterized R at PS time.

Any progress on spreadsheet for her?

 

[JL and Chip]

You have used R before?

Yes, used combo of Lantus and R with Charlie but that was years ago and JoJo was around back then to guide me. I’d definitely need a refresher and want someone with objective eyes to advise.

I also used R for Tubby in combination with Prozinc but that was an entirely different beast. I don’t advise it.

I don’t have any R that isn’t expired but will plan to pick some up tomorrow.

I’m trying to track down my google account info and credentials. I’ll be tackling that in the next couple of hours.

 

[Wendy&Neko]

Let me know once you have the R. I learned R by watching Jill (and others including Sandy) help with it, and Jill and Sandy learned from Jojo. But only used it myself with Lev. Principles are the same - you don't want the two insulins to nadir at the same time, the two L's just happen at different times so sometimes R shots get moved.

 

[Wendy&Neko]

One last thing, what time zone are you in and what time there is your PS time? Would be good to get an R helper awake during your preshot times.

 

[Bron and Sheba (GA)]

How are things going?

 

[JL and Chip]

How are things going?

Ketones 5.3 now and she’s hospitalized getting IV fluids. She’ll be coming home later today, at least that a the plan. It’s been a lot of up and down, sometimes waaaaaay down. Thanks for asking.

 

[Bron and Sheba (GA)]

I’m very glad she made it to get the IV fluids. I wonder if a cerenia injection on discharge would help with the nausea as well as the ondansetron. Any more discussion about the feeding tube?

 

[JL and Chip]

4/19 PM update:

• RK spent the day hospitalized on IV fluids. Ketones were 6.4 overnight last night, 5.3 going in this AM, and now down to 0.2
• She’s eating on her own at the moment — high carb canned and dry food, but I’ll take it. She’s shown very little interest in any food up till now.
• She’s much brighter and more alert. It’s the best I’ve seen her since diagnosis.
• PM shot was a little over an hour late due to hospitalization but PMPS is 142 (lowest since started this damce). I shot the fill 0.5u dose and will monitor closely.
• Picked up R from the pharmacy putting a hold on using it depending on where this goes.
• Yesterday she was a lump who looked and acted like she wanted to die. Amazing how quickly this ketone monster pivots. I’m not letting down my guard!

 

[Wendy&Neko]

I am holding my breathe and crossing fingers, toes and paws from here. Healing vines headed RK's way. Were you around when the KTSS (kitten travelling soup and spa) was a thing?

 

[Bron and Sheba (GA)]

I am so happy to read this update and also crossing my fingers things stay stable. What a remarkable turnaround.
Great she is eating…whatever she will eat is fine.
You are doing an amazing job looking after her!

 

[JL and Chip]

Well, at PM +6 we’re back up to 542 and ketones at 1.9.

She was very interested in food immediately after discharge but less so now. She still sniffs and nibbles, but not nearly as much. Despite being wobbly and weak, she’s engaged and opinionated—and determined to go back to bed after I woke her for testing.

On any other night I might consider a drop of R given we’re trending upward and still have 6 hours before AM shot, but I’m not sure I have it in me to pull another all nighter. Hopefully this is just a small blip.

Any more discussion about the feeding tube?

Not yet. Will likely reevaluate next week.

Were you around when the KTSS (kitten travelling soup and spa) was a thing?

Hmmm, I’m not sure I remember that. But I do remember those late nights when Sandy and Black Kitty were shooting some crazy doses. There is truly a lot of history in this group. Too bad the database from the old board was lost. It was a treasure trove of information.

 

[Bron and Sheba (GA)]

What about sub Q fluids? Did the vet mention continuing those. She seems to respond to hydration. Is she still getting the ondansetron?
It might be worthwhile also using cerenia as well as the ondansetron.

 

[JL and Chip]

What about sub Q fluids? Did the vet mention continuing those. She seems to respond to hydration. Is she still getting the ondansetron?
It might be worthwhile also using cerenia as well as the ondansetron.

Yes to both subQ and Ondansetron. I gave both a little bit ago as it seems she’s already starting to dehydrate. I have a couple of doses of injectable Cerenia just in case but haven’t used them since she’s not vomiting.

One of the vets suggested a low dose of gabapentin. Is that a helpful for DKA recovery?

 

[Bron and Sheba (GA)]

The cerenia might still help with the nausea. As you know it can be given at the same time as ondansetron as they work on different pathways.
I have not seen gabapentin given for DKA unless there is another issue to be honest. Is she anxious? Or in pain?
I would be concerned it would make her drowsy and she might be even less inclined to eat.