10/1 Heart DKA Update - Advice Please

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dodgingwrenches

dodgingwrenches

Member Since 2010
Just an update on my thread, and some advice requested (previous thread viewtopic.php?f=9&t=105433)

The vet just called me, and they want to keep Heart another night (a few hours ago, they were going to send him home with me tonight)

I just want to run this by you guys, since I am so suspicious of vets and their treatment of diabetes based on my experience when Heart was first diagnosed - his diabetes was completely mismanaged by my old Ottawa vet, and it wasn't until I turned to you guys and switched him to Lantus after learning about it from you, that I got him into remission. He spent three years at the Falls. That said, my Toronto vet here is FANTASTIC. I do trust him, and he took great care of my ferrets. But this is now my sugar cat, and I am extra sensitive about how he is treated based on my bad experience three years ago...

Anyway, Heart went in because of "moderate" Ketones yesterday (my first time seeing Ketones with him) and because he was no longer eating, drinking, or peeing. He has been on an IV for 24 hours now. Ketones this morning were negative again, and he's eating, drinking, and peeing, but his BG has jumped up - was 17mmol (306 in U.S.) just 24 hours ago, now is in the high 20s (~470). This could be due to the glucose drip he's been on because of the DKA (glucose has now been discontinued).

So the vet just called and asked to keep him another night. Said that he is still very dehydrated, and he wants to get him re-hydrated and his BG down to mid-teens again before sending him home for me to resume his lantus protocol. He's been getting 1.5 units of Lantus. They want to also add in a fast acting insulin as well though (in addition to the lantus) just to try and get his BG down. They are worried that if I take him home tonight, and he's still dehydrated and his BG is super high, he'll end up with DKA again. I'm not sure what to do... Part of me wants to take him home and resume his Lantus regime in the comfort of his home. We've had the super high BGs before for weeks. But, he's never had DKA before. I'm also not sure about mixing Lantus with a fast-acting insulin. I don't want his BG bouncing around either.
 
Have you given sub-q fluids at home before?

I have zero experience with using a fast acting insulin but others here do. Let me see if I can find someone to chime in with help for that.

I understand their concerns about the ketones coming back and getting him hydrated. If you haven't given fluids before, it's not that big a deal.
 
I have given SubQ fluids before when I had a cat with acute kidney failure. I guess I could propose that as an alternative...
 
OK, then the fluids part is easy. We just need someone to input on managing "R" with Lantus. How long before the vet closes?
 
Do you know if the fluids he's getting now are just "straight" or if they are still supplementing to make sure his electrolytes are all good? (Assuming they were adding something to the mix)
 
dodgingwrenches said:
So the vet just called and asked to keep him another night. Said that he is still very dehydrated, and he wants to get him re-hydrated and his BG down to mid-teens again before sending him home for me to resume his lantus protocol. He's been getting 1.5 units of Lantus. They want to also add in a fast acting insulin as well though (in addition to the lantus) just to try and get his BG down. They are worried that if I take him home tonight, and he's still dehydrated and his BG is super high, he'll end up with DKA again. I'm not sure what to do... Part of me wants to take him home and resume his Lantus regime in the comfort of his home. We've had the super high BGs before for weeks. But, he's never had DKA before. I'm also not sure about mixing Lantus with a fast-acting insulin. I don't want his BG bouncing around either.
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i've dealt with DKA. alex is a ketone prone kitty. i've used R to help pull her numbers down and to keep ketones at bay. i also trust my vet and i know the seriousness of ketones. if i were in your shoes and another night's stay was possible... i'd leave him there. if you let your vet stabilize him before you take him home there will be less chance of him relapsing after getting him home. fwiw, from what you've said... i agree with your vet's plan and i share your vet's concerns about bringing him home tonight.

when you do get him home... whenever that is:
if you have trouble keeping his numbers down, his appy is off, and/or he shows even a trace of ketones post for help immediately. there are several of us who can offer suggestions up to and including incorporating the use of R into his treatment plan at home. you'll want to continue to test for ketones often because it's a lot easier and less expensive to nip them in the bud than to have to deal with moderate/high ketones or DKA.

since you already know how to give fluids, ask them for supplies to administer fluids at home: a bag of fluids (usually LRS), a line, and needles. i always keep a set up on hand just in case alex needs fluids when my vet's office is closed. it invariably happens on a weekend or late at night. :o

just my thoughts...
 
You might edit your topic to add "Q - Using R bolus" to get more input.

I used R with Spitzer when he was too erratic to just increase Lantus.
- It is in and out in roughly 4-5 hours.
- You can give tiny doses (drops, or 0.25 units) and drop like a rock, so you have to be monitoring.
- It worked, and quickly.
- It is inexpensive.
- You can do this at home if you are able to monitor, or have enough data to feel safe using it.
- it is helpful when you cannot raise Lantus due to variable appetite, vomiting, or other major impacts on the glucose, and need to bring it down.
 
Here is my concern though - it's not a 24 hour clinic. They close at 8 today, so he'll be unsupervised for 12 hours and nobody will be giving him anything. He's just getting the fast-acting insulin until they close. He's not as hydrated today as he should have been, since something happened with his IV overnight, so he didn't even get fluids all night. I don't like him being all alone....
 
Carl & Bob said:
Do you know if the fluids he's getting now are just "straight" or if they are still supplementing to make sure his electrolytes are all good? (Assuming they were adding something to the mix)
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He was on fluids and glucose drip overnight. They discontinued the glucose drip today and are just giving fluids. Anyway, going to go check on him now before I make a decision. Have until 7:30pm to decide (they close at 8pm)
 
If he were in a 24 hour clinic, that would be the best. Not having someone there who knows what's going on is not a good thing.
 
dodgingwrenches said:
Here is my concern though - it's not a 24 hour clinic. They close at 8 today, so he'll be unsupervised for 12 hours and nobody will be giving him anything. He's just getting the fast-acting insulin until they close. He's not as hydrated today as he should have been, since something happened with his IV overnight, so he didn't even get fluids all night. I don't like him being all alone....
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okay. that sheds a different light on the subject. i assumed he was at a 24 hour facility.

a 24 hour clinic is the best option for heart, but if that's out of the realm of possibility...

if you want to bring him home because he won't get anything there overnight you could give him fluids at home tonight & tomorrow (ask them how much and how often to give). if you need a refresher course on giving fluids, ask them for a demonstration before you leave their office. find out which insulins they gave him today, how much, when given, and all data collected from their spot checks (put the info on his ss). also find out when he's eaten and how much he ate. pick up a vial of Humulin R or Novolin R at a drug store to use in case it's needed tonight. post often. if he'll need a bolus of R we can walk you through it. please don't attempt to use R on your own until you've had some guidance. it's a strong and powerful insulin and can be dangerous if not used correctly.

you have to decide if you're willing and able to stay awake tonight for as long as it takes if you elect to use R. initially, spot checks must be performed every hour for 4 - 5 hours. if the R pulls him down to lower numbers, further testing may be required... won't know til we see what happens. we can get into more specifics of R use later, but i wanted to prepare you for what to expect if you use R at home.
 
I did leave him there, just because of the dehydration. So he's on a fluids drip plus they are putting him on a light glucose drip for safety overnight. Tomorrow they will if needed give more R. I don't remember the name of the one they used, but he said it's out of his system very quickly, in 2-3 hours. BG on the vet's AlphaTrak was 252 (vs 239 on my Freestyle Lite with expired strips). So definitely better from earlier today. I decided to wait to take him home until he was fully hydrated since I don't want ketones coming back.
 
It is likely called one of the following: Novolin R, Humulin R, "Regular" insulin, or Toronto insulin. They are all the same thing. R is a short-acting insulin. It lasts about 4 hours with nadir at around +2.

What your vet described is the typical treatment for DKA/ketones. They administer fluids. They increase the basal insulin (i.e., Lantus) and use a bolus insulin like R to bring the BG numbers down. At the same time, they use a glucose drip to keep your kitty safe and to provide some form of nutrition.

Do you know if Heart's white blood count was elevated or if there's any source of infection? Often infection/inflammation (like from an infection or the need of a dental) + not eating + not enough insulin result in ketones.

You will need to continue to test Heart at home. Ketones can recur so getting a test whenever you can is important. Alternatively, you can get a meter that measure blood ketones (e.g., a Precision Xtra or a NovoMax meter).
 
I don't think they did a white blood count in the blood work. He didn't do a full blood work, just a diabetic work-up. Since I had complete blood work from two months ago, and there was no temperature. This vet goes a lot based on gut and avoids "unnecessary" testing (and he is truly amazing - a top vet in Toronto) as he is conscious of his client's wallets (unlike many others). So that is both great, but can be risky as well I guess.

That said, this tooth thing is bothering me. I did ask about a dental, but the vet wants Heart's BG stabilized first before any surgery. Then I am thinking - can he stabilized/go into remission while he has an infected tooth (has a cavity)? Anyway, I left a message to talk to the vet about getting it extracted again. It's nagging me and I barely got any sleep last night thinking about Heart. Or at a minimum, antibiotics?
 
Hi guys, no advice from me, but wanted to add in my prayers that Heart starts feeling better asap and can come home soon!
 
While you're up losing sleep (and I'm sorry to hear that you are), you can read about the others here who have dental work done on their FD cats, to put your mind at rest.
Best wishes!
 
Good to hear that Heart's numbers are coming down. Has Heart ever had a dental before? Do you know how he reacts to anesthetics?

If you are having a hard time getting ketone tests consider getting the Tidy Cats Breeze litter box. The 'litter' is non absorbent pellets, urine goes through to an absorbent pad. It is easy to pull out the drawer w/ the pad put some plastic wrap over it to catch the urine and test from that. Plus there is practically no litter odor.
 
Heart had a dental two years ago, so that's why it surprised me he needs another already. So yes, he's had one. And he'll be getting another, just not yet. Vet doesn't want to subject him to anaesthesia until he's stable. Doesn't want to give him antibiotics either, because that will impact his appetite and he needs to eat. So, plan is I bring him home today. In a week we do a follow-up, and then possible give him antibiotics until he can have his dental in a few weeks.
 
The Tidy Breeze looks interesting, but I have two cats, and they are both BIG cats. They need a big boy box :)

Catching urine isn't hard. I just stick the stick under his butt while he's peeing.

I like the idea of not tracking litter through the house though - maybe if they make a jumbo breeze box one day.... Right now, I have to vacuum every day since they track the litter everywhere!
 
Have you ever tried a litter mat? I know some pet stores sell different versions of these... They really do help. My cats used to scatter litter everywhere too but this seems to help a LOT.

This is a link to one from Petco : http://www.petco.com/product/123069/Pet ... SiteSearch

The mat is designed to catch the litter... The ones from pet stores are a little more expensive and usually smaller in size. I bought a rubber door mat from our local dollar general store. Its a rubber mat and its textured so it catches the litter. I am trying to find a link to one so you can see what it looks like...

I think I paid $3 for the mat and its a size of a normal door mat. If you put that at the entrance of the litter box it should really help!
 
Oh yeah, various mats of various sizes! Cut it down quite a bit, but still get the odd little pebbles making their way all the way to the bedroom :)
 
The Tidy Breeze looks interesting, but I have two cats, and they are both BIG cats. They need a big boy box :)
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I have a 24 pounder that has no trouble using the Breeze..Unfortunately, it's not China. She doesn't like the feel of the pellets. If it's something you think might be worth trying, I wouldn't worry about the size..unless Heart is a really big kitty!
 
You might improvise using some heavy duty screening and something oily, like sunflower seeds, which wouldn't absorb the urine, letting it pass through the screen to whatever you wanted below - absorbent pad, newspaper, a hose to a floor drain, etc.
 
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