DKA Again- I'm So Lost

Alyce & Elkie

Alyce & Elkie

Member
My boy was ketone free when I took him home yesterday agter spending 3 nights at the vets in DKA, he wasn't given any antibiotics, I tested before work around an hour ago and it's about to be the weekend. His ketones are high again at 3.3! Is it because I didn't give enough insulin again? I followed the advice I was given on the Facebook extension of this group, and disregarded the vet's instructions of giving 4 units and gave his usual dose of 2 at 3am, as I wouldn't be able to test frequently. He remained above 20mmol glucose levels, although he went up to 33 at the vets. He shouldn't be this high in ketones today, after being at the vets all that time to get them down. :( I'm not allowed to add any more to my bill, anything else needs to be paid day of treatment. I already owe 2 thousand NZD. I'm possibly transferring vets to set up a second debt, I'm at a loss. I don't know how to save my boy.
 
Alyce & Elkie said:
3am it's now almost 12 noon.
He has been eating a little at a time, not a lot like usual.
I could go to vet after work but does he need admitted over weekend? They aren't even there much over weekend. :(
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Have you tried waking him up and stimulate him? Have you tested his BG?
 
Alyce & Elkie said:
3am it's now almost 12 noon.
He has been eating a little at a time, not a lot like usual.
I could go to vet after work but does he need admitted over weekend? They aren't even there much over weekend. :(
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That's how my vet is over weekends. There's not really anyone there. If you can get a bag of subcutaneous fluids, the members on this forum can help you administer them. They helped me. The fluids help flush out the ketones. Elkie needs food, Insulin, and fluids.

My bag cost $30 US. Once open, you can use it for 2 weeks. Unopened, the shelf life is very long.
 
CORKY said:
Have you tried waking him up and stimulate him? Have you tested his BG?
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I'm at work, I left 2 hours ago, I still have 3 hours left of my shift. Was going to work until 8pm tonight but since all this is happening I plan to leave at 3 as that's my rostered finish time. :(
 
I know this is so stressful. Have you been keeping a spreadsheet? I ask because it’s hard to know about dosing as Sienne said. When you get home if you could either set one up or post the last week of tests and doses it would help. If he won’t be watched at the vet it seems like that’s not an option. Is there an ER close enough if needed?
 
He needs to eat about 1.5 times his normal amount of food. Can you get anything to help him eat? Frankly, at this point you can feed him whatever he will eat. We will worry about carb content later. Water down food to help with fluid intake. See if the vet will get you a prescription for ondanetron (first choice) or Cerenia to help with nausea. Mirataz is an appetite stimulant that can also help.

He also needs insulin. The formula for DKA is not enough food + not enough insulin + infection or systemic inflammation. Did they discover any infection or inflammation like pancreatitis? Reducing insulin too much can also be a problem.

A couple posts on feeding:
 
Wendy&Neko said:
He needs to eat about 1.5 times his normal amount of food. Can you get anything to help him eat? Frankly, at this point you can feed him whatever he will eat. We will worry about carb content later. Water down food to help with fluid intake. See if the vet will get you a prescription for ondanetron (first choice) or Cerenia to help with nausea. Mirataz is an appetite stimulant that can also help.

He also needs insulin. The formula for DKA is not enough food + not enough insulin + infection or systemic inflammation. Did they discover any infection or inflammation like pancreatitis? Reducing insulin too much can also be a problem.

A couple posts on feeding:
Click to expand...

She's got some kibble that she's going to try to see if he'll eat it but I'm concerned that it will increase his BG which will make her even more concerned. Trying to explain that it's not the glucose right now that we need to worry about as much as getting enough food into him to stop the production of ketones.

The vet only had him on a short-acting insulin drip (which is turned off when they aren't there) and vet gave him 4U of Lantus right before sending him home and told her to give 4. From previous posts, she had said that 2U had dropped him too low so she dropped back to 1U (was using the pen with pen needles instead of syringes) which is why we suggested only doing the 2U. Also, since he wasn't getting the lantus during his hospitalization, the depot needs to build up again.

She is really wanting to increase the insulin but we're not comfortable with that but have told her that she holds the syringe. She's also still wondering if she should hospitalize him again (which we don't think will be terribly useful since nobody will be there after noon tomorrow and they turn off the insulin when they leave)

Any advice and help with explanations is much appreciated. Sometimes somebody else can explain things differently so that it makes more sense.
 
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Wendy&Neko said:
Once we can see a spreadsheet, we'll be better able to help.
Click to expand...

I set one up for her but she hasn't put any numbers in it. I'll stress that she needs to start from today and work back until April 1.

It's already past her shot time and she is wanting to give 3U. The vet is now saying 4 is too much since he's not eating and doesn't believe the blood ketone meter is accurate because "they use them on cows but haven't used it cats"

https://docs.google.com/spreadsheets/d/1r1PyXeWmzScbbQAcWi_cc87Iy75pxCzHIJkStyNlwcA/edit?gid=0#gid=0

ETA: She went ahead and gave 3U
 
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Wendy&Neko said:
See if the vet will get you a prescription for ondanetron (first choice) or Cerenia to help with nausea. Mirataz is an appetite stimulant that can also help.
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Vet gave her ondansetron, 4mg, 1/2 tab q 12hrs.

Vet just told her "she could come get something for appetite she can give every 3 days" (so mirtazapine)

ETA: she is going to go pick up the mirtazapine, feeding syringe, Hills AD or Royal Canin Recovery food and some honey/syrup, and high carb cat food.
 
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Ondansetron can be given every 6 hours if needed, maybe start with every 8. Hopefully she'll get Mirataz instead of mirtazapine pills. Mirtazapine and ondansetron target the same nausea receptors and mirtazapine has better ability to attach. Meaning ondansetron should be given first.
 
I'm going to be trying to get some sleep soon. I wanted to keep you guys updated on what she's been telling us. I'm glad to see she's posting here so I will tell her to update you when she's home.

ETA: he's eating some canned food (and looks like he's eating quite eagerly) so hopefully she'll be able to deal with this at home. I have explained the difference between ketosis and DKA to her too.
 
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Hi everyone sorry I haven't been replying here, I need to check the forums more frequently. I've been quite stressed and phoning two different vet clinics as I wasn't confident about the opinion of the first.

They said it wasn't in Elkie's best interest to come in due to his stress levels, they weren't convinced on the accuracy or a human blood ketone monitor on cats. They said they use a spin down machine to separate the plasma, or something along those lines, and wanted me to get a sample with the urine strips. I did, which shows as either negative for ketones or traces, difficult to tell. Not sure whether to believe that or the meter. I read that ketone blood meters were more accurate than urine strips, and that urine strips may miss ketones at lower levels.

Not sure what's true and what isn't, but his urine ketone test was significantly better than it was when I had him hospitalised. It was on the second or third highest at that point.

The second clinic agreed Elkie could stay home, as long as he's eating and not lethargic. He's not scoffing his food like he was before he started getting nauseous/developing ketones, but he is eating. I did give him 3 units of insulin as the 2 wasn't bringing him down much, but I'm keeping an eye on him. I'm testing, and I have higher carb food, liquid honey, and a feeding syringe on hand if needed. He's had a Mirtazapine to increase his appetite, and I have Periset (Ondansetron) for nausea which I'll give him at some point. I can't remember when I gave one last, think it was sometime overnight.

The vet wouldn't let me take any fluids home, but I can call either clinic tomorrow if needed and pay after-hours fees. I'm not sure whether to give 3 units again at his next shot time around 4am, I guess it depends on his numbers.


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Wendy&Neko said:
Ondansetron can be given every 6 hours if needed, maybe start with every 8. Hopefully she'll get Mirataz instead of mirtazapine pills. Mirtazapine and ondansetron target the same nausea receptors and mirtazapine has better ability to attach. Meaning ondansetron should be given first.
Click to expand...

Thanks, I mentioned the ointment for the ear but they gave me Mirtazapine pills.


Wendy&Neko said:
He needs to eat about 1.5 times his normal amount of food. Can you get anything to help him eat? Frankly, at this point you can feed him whatever he will eat. We will worry about carb content later. Water down food to help with fluid intake. See if the vet will get you a prescription for ondanetron (first choice) or Cerenia to help with nausea. Mirataz is an appetite stimulant that can also help.

He also needs insulin. The formula for DKA is not enough food + not enough insulin + infection or systemic inflammation. Did they discover any infection or inflammation like pancreatitis? Reducing insulin too much can also be a problem.

A couple posts on feeding:
Click to expand...

Thanks, he's eating a decent amount now. :) No they didn't, I know they ran some tests before treating him but don't think they checked for infection or inflammation. I think they were more checking his glucose levels and potassium. They didn't check his kidneys either.
 
Alyce & Elkie said:
wanted me to get a sample with the urine strips. I did, which shows as either negative for ketones or traces, difficult to tell. Not sure whether to believe that or the meter. I read that ketone blood meters were more accurate than urine strips, and that urine strips may miss ketones at lower levels.
Click to expand...

It wouldn't hurt to try the blood ketone meter again and see if you get a result that's more in line with the urine strips. It's possible to get a false high reading from touching the blood meter strip where the sample goes. I think I might have done that very thing. The high reading scared the crap out of me.

I have found the meter very accurate when I don't touch the contact point for the sample. :facepalm::facepalm::facepalm:
 
Kobe (Dean and Lesley) MO said:
It wouldn't hurt to try the blood ketone meter again and see if you get a result that's more in line with the urine strips. It's possible to get a false high reading from touching the blood meter strip where the sample goes. I think I might have done that very thing. The high reading scared the crap out of me.

I have found the meter very accurate when I don't touch the contact point for the sample. :facepalm::facepalm::facepalm:
Click to expand...

Thanks, I'll test again in the morning but I did make sure not to touch the strip
 
Human blood ketones meters have been used on cats for ages. There's even a couple papers 2012 talking about them, from this post: Ketones, Diabetic Ketoacidosis (DKA), and Blood Ketone Meters:

When do ketones show up on a blood ketone meter such as the Nova Max Plus or Precision Xtra Blood & Ketone meters?
Two of the latest scientific studies (linked below) concerning measurement of ketones when using a blood ketone meter provide an up-to-date interpretation that when a blood ketone concentration of 2.4 and 2.55 are obtained, DKA is more likely to be present.

Measurement of ketones - Weingart_J VET Diagn Invest-2012(1).pdf
Measuring ketones - JSAP_Zeugswetter - 2012.pdf
 
tiffmaxee said:
I know this is so stressful. Have you been keeping a spreadsheet? I ask because it’s hard to know about dosing as Sienne said. When you get home if you could either set one up or post the last week of tests and doses it would help. If he won’t be watched at the vet it seems like that’s not an option. Is there an ER close enough if needed?
Click to expand...
I'm working on it, my monitor had the wrong dates so busy trying to convert everything to the right dates. :)- There are on-call vets if needed.
 
Wendy&Neko said:
Human blood ketones meters have been used on cats for ages. There's even a couple papers 2012 talking about them, from this post: Ketones, Diabetic Ketoacidosis (DKA), and Blood Ketone Meters:

When do ketones show up on a blood ketone meter such as the Nova Max Plus or Precision Xtra Blood & Ketone meters?
Two of the latest scientific studies (linked below) concerning measurement of ketones when using a blood ketone meter provide an up-to-date interpretation that when a blood ketone concentration of 2.4 and 2.55 are obtained, DKA is more likely to be present.

Measurement of ketones - Weingart_J VET Diagn Invest-2012(1).pdf
Measuring ketones - JSAP_Zeugswetter - 2012.pdf
Click to expand...

I hope he's not in DKA again, I only just got him home. :/
 
Kobe (Dean and Lesley) MO said:
Well, it's good that you are more careful than I was. I still don't know if I touched the strip or not. :facepalm: Hopefully the reading is better this morning. Great news about the return of Elkie's appetite. Kobe and I will keep fingers and paws crossed for you and Elkie. :):):)
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Thank you. His reading is 17.6 now preshot, will probably give 3 units again due to ketones and still being high, although he's getting closer to his original levels on 2 units. (11-16, averaging around 15) He was 33 when the vets gave him 4 units before sending him home Thursday afternoon. I gave him 2 units next dose around 3am and he stayed between 20.5 and 21.2. Gave him 3 units at his next dose around 4pm (was late dosing but slowly working towards his usual 9am) and he's gone from 19.3 at +2 to 17.6 now. Its just after 4am now, hoping 3 is still good as I'm home most of the day today to keep an eye on him.
 
I've given 3 units around 4:15am, slightly late as was supposed to be around 4. I was deciding whether to lower the dose or not as he's getting closer to his original numbers at 17.6. Sometimes his levels barely move at 2 units and other times they fluctuate between 11-15. I'll likely not be sticking with 3, it's just for the meantime since he still has ketones and he's still well above safe kidney levels. I have higher carb food and honey on hand if needed.
 
We do get the occasional cat be OK above 2.4. But do keep testing those ketones and getting what food and liquids you can into him.

Lantus does better with our dosing methods if you can try to keep the same dose, instead of changing each cycle.
 
Wendy&Neko said:
We do get the occasional cat be OK above 2.4. But do keep testing those ketones and getting what food and liquids you can into him.

Lantus does better with our dosing methods if you can try to keep the same dose, instead of changing each cycle.
Click to expand...

Thanks, I'll keep him on 3 units then for the time being, depending on his nadir and pre-shots not being significantly lower of course. His ketone reading this morning was 0.8. :)
 
You are doing a great job Alyce with Elkie.
Keep up with lots of food and I agree with Wendy, re the dose of insulin. I would stay with 3 units unless Elkie low.
Good news the ketones are down to 0.8!
 
Sienne and Gabby (GA) said:
Alyce -- are you adding water to Elkie's food? Fluids of any sort may help.
Click to expand...

I tried as that's what I usually do but he's not that interested in his pate right now, even less so if I add water. He's having a lot of raw meat, and tuna in jelly (cat food). The latter isn't ideal but it seems to stimulate his appetite, and he really likes it. He's been drinking a fair bit.
 
Your spreadsheet is showing little BG drops on 2, 3 and 4 units of Lantus. Also.overall BG level was lower on 2 units. However, that was before the DKA.
The relatively high BGs on the current 3 units is likely contributing to the ketones. Did the ER vet say anything about the cause of the DKA and little drop in BGs? Was bloodwork done?
 
Larry and Kitties said:
Your spreadsheet is showing little BG drops on 2, 3 and 4 units of Lantus. Also.overall BG level was lower on 2 units. However, that was before the DKA.
The relatively high BGs on the current 3 units is likely contributing to the ketones. Did the ER vet say anything about the cause of the DKA and little drop in BGs? Was bloodwork done?
Click to expand...

I've just received the results from the tests they did and looks like they only tested sodium and chloride, both of which where slightly low but barely. They didn't mention a cause, they were too busy trying to push me to euthanise due to quality of life, as he was highly stressed at the vets and they were having trouble treating him. He never attacked anyone, just hissed and growled.
 
Sienne and Gabby (GA) said:
Alyce -- are you adding water to Elkie's food? Fluids of any sort may help.
Click to expand...

I have been but he hasn't really been eating his pate much lately, preferring his raw meat. It will usually sit there overnight... he's drinking a lot though and ate his pate tonight with a little water in. Also had his pate last night!
 
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