Need advice, just got back from urgent care. When to hospitalize vs. monitor w/ pancreatitis?

[hellolucy]

Really struggling with the best place for my girl Lucy (senior cat, diabetic now for ~10 years, severe arthritis) and looking for some advice as I know pancreatitis and diabetes are a pair. Lucy has had such a rough couple of months. We took her in to urgent care this morning. She vomited several times last night and wanted nothing to do with her food this morning which is really unusual for her. She was also being very lethargic and sort of leaning over in to her water bowl, just looked very bad/wobbly/weak and her glucose readings have been very high for several days out of nowhere but she has otherwise seemed okay, just went downhill so fast overnight.

They did a CBC and urine dipstick test. Came back with signs of dehydration, elevated cholesterol, and high white blood cell count. Based on the findings and ruling out some other things, they think she may have a UTI and pancreatitis. They said a snap test would take several days to come back and they did not have an ultrasound in house to verify pancreatitis.

They said they could hospitalize her by moving her to ER or try out patient care. The urgent care vet said because her other numbers looked okay (electrolytes, potassium, and blood pressure), she said she didn't think it was necessary to hospitalize her at this point but to keep a very close eye on her. I struggled very, very much with deciding what to do. It's just me at home right now. They did out patient care - fluids, Cerenia shot, gave me antibiotics to start tonight, and some pain meds to take home (buprenorphine) along with Cerenia pills. We have an appetite simulant at home from a previous visit as well. We just got home about an hour ago and she is still very lethargic/wobbly and just not really moving. Still no interest in any food. She's awake/sort of looking around but clearly not feeling good at all.

When is it right to hospitalize for pancreatitis vs. monitor at home? I am definitely hovering and not sure if this is 'normal' for pancreatitis and how long it takes to get better.

Edit to add: it is not DKA. I tested her this morning with Ketostix and they tested her again at urgent care.

 

[Wendy&Neko]

I'm starting with a post talking about pancreatitis and treatment: A Primer On Pancreatitis I'm glad you've got fluids and pain relief (bupe), Cerenia is OK, but in my opinion ondansetron is a better anti nausea medication. I've seen a lot of differences in cats on how severe and how long the pancreatitis lasts. Neko I could easily manage at home, with the right meds and a bit of syringe feeding to get her started.

• Suggestions on How to Stimulate Kitty's Appetite
• Syringe/Assisted Feeding (Video and Tips)

Tagging @tiffmaxee who has more experience with it in her cat.

 

[Sienne and Gabby (GA)]

If they had the Snap fPL to diagnose pancreatitis, this is an immediate result test. I'm guessing they meant a Spec fPL which is sent out to IDEXX.

I would just keep a close eye on your kitty. If you don't have Ketostix at home, I'd suggest picking some up as a precaution. If you start to see more than trace ketones, it would be a deciding factor regarding more aggressive medical management.

 

[hellolucy]

Syringe/Assisted Feeding (Video and Tips)

I would just keep a close eye on your kitty

Update: I went to the CVS next door to get some syringes to assist feed her, gone for maybe 20 minutes. Got back and she was laying half way out of her bed with her mouth slightly open. She was making a strange 'huffing' noise every minute or so. She had bupe about a month ago for a abcess in her mouth and did just fine with it. I wonder if this time it hit her especially hard because she hasn't been eating. Either way, she scared me half to death with the way she looked when I walked in...immediately picked her up and drove to the ER and they took her right back. They sent me home and said the doctor would call in a couple of hours but that they would be monitoring her. I would normally just wait/stay there but was exhausted from being up with her last night vomiting and then urgent care most of the day today but I know she's in the best place she can be right now. They did say she had a temperature upon check in at the ER so now I really don't know what is going on

 

[JL and Chip]

Oh wow, what a roller coaster.
Whatever is going on, it sounds like a very good idea that you got her back to the ER. Any breathing abnormalities in cats are concerning.

I’m so sorry you’re going through this.
It’s scary and exhausting and overwhelming. Please post updates when you can.

 

[Diane Tyler's Mom GA]

Sending prayers for your beautiful Lucy. ♥

 

[hellolucy]

Oh wow, what a roller coaster.
Whatever is going on, it sounds like a very good idea that you got her back to the ER. Any breathing abnormalities in cats are concerning.

I’m so sorry you’re going through this.
It’s scary and exhausting and overwhelming. Please post updates when you can.

Sending prayers for your beautiful Lucy. ♥

Thank you both

Vet called and said she had a temp of 104 upon intake - mentioned that pain meds can slightly increase temp as well. They are doing a full urinalysis which will be back in a couple of days (urgent care just did dipstick) and starting her on IV antibiotics just in case it is a UTI 'that is becoming systemic'. They are going to start her on low dose fluids as well since she received some earlier today at urgent care but did mention she looked dehydrated. They indicated her breathing looked normal, heart and lungs sounded good, but they are putting her on respiratory watch just in case overnight. Doing another CBC and ketone test. They are also recommending an ultrasound tomorrow to confirm pancreatitis rather than Snap. Will get a call tomorrow morning to see where she's at.

Side note in case any members have experience - the ER vet noted that she had an abdominal ultrasound at her regular vet about a month ago and at that time, her normal vet recommended a test for hyperaldosteronism/hyperadrenocorticism or acromegaly based on what they saw. I never got around to doing it as some pretty severe medical emergencies came up with my parents (2024 has been kicking me in the butt so far). I know the terms just from general proximity in my readings trying to help Miss Lucy, but don't know much more about them. Wondering if something related to those has been causing all these recurring issues for her.

 

[Wendy&Neko]

I'm glad she's getting vet care tonight. I hope it means you can get some sleep.

The more common name for hyperadrenocorticism is Cushing's, so you might see more information about that. It'd be interesting to see what they saw during her ultrasound. Acromegaly can cause larger organs due to excess growth hormone. Both acromegaly and Cushings can result in pot belly, though not always with acro. Cushings often shows with skin condition, thin skin, maybe freckly like appearance, thinning hair on the belly, and in worst case skin tears. However, with both acro and Cushings, diabetes tends to be a later stage of the disease and you wouldn't see them still around after 10 years.

Hyperaldosteronism is not something we see much here, more details here.

 

[Larry and Kitties]

They said a snap test would take several days to come back

That does not make sense. The snap test is done at the vet by applying blood to a small device. It takes 10 ,minutes to get results. You gat a res/no result.
https://www.idexx.com/en/veterinary/support/documents-resources/snap-fpl-test-resources/
One can send blood sample to lab and get get a nermerical result and that takes a couple days.

 

[hellolucy]

Update and long post, just overwhelmed and not very impressed with ER she was at, they were very dodgy with so many of my questions despite me pressing: Lucy is home and I'm nervous about it. She was in the ER for just about 24 hours, doctor said she was in condition now to be monitored at home. I hate this back and forth in my mind of worrying about wrong decisions, am sure many here can relate!

Her fever dropped overnight from 104 to 102.5 while in ER. They indicated she did not eat during the night but was eating small amounts throughout the day. They said her urine smelled very strong and believe she has a UTI, results back in about 2 days. Received IV antibiotics and more to continue at home. Ketones and electrolytes were okay at last check. They did not do any test for pancreatitis. They said if she is not better in 3 - 5 days or going downward quickly, ultrasound is next step. They noted she had an abdominal ultrasound a month ago and everything looked fine but that seems like a lot could happen in a month with pancreatitis? She has been in the urgent care/ER so many times over the past 3 months, not sure what is going on with her but is killing me financially (and mentally) in such a short period. The ultrasound was $900 and now I wish I would have asked for one of the other blood tests for pancreatitis just to understand what is going on more.

Since we got home, she is still clearly very lethargic, 'dragging', and hasn't moved. I would attribute some of this to just being exhausted right now so figure tomorrow will be more telling as far as reality goes. I am feeding her small amounts (about 1 - 2 TBSP) every 30 minutes or so. She is really interested in Fancy Feast and a Churu stick, neither of which are part of her normal diet. My concern with these is complications with her IBD as well as her numbers are already high again at home (500+). They were mid-200's at the ER with short acting insulin. Do I just get her to eat whatever she can right now? I gave her the normal insulin dose tonight because her number was so high and I'll be up at least 3x anyway to check during the night in case it gets too low.

For at home meds, they gave me Cerenia, Ondansetron, Bupe, Clavamox, and Mirtazapine. They stopped her fluids around ~6PM tonight and I have a bag from urgent care (assuming I can do this at 6PM tomorrow?). They did not give her any pain meds at the ER which seems crazy to me when it is likely pancreatitis. Can I give her Bupe with these other medications? I know pain management is critical right now. I couldn't find a solid answer on this when searching.

A few other random questions:
- I haven't seen her drink water yet and we have been home about 3 hours. Similar to assisted feeding, should I do the same with water?
- Related to above...do I wait 24 hours to give a large dose of fluids?
- Mentioned above but unsure of how to proceed with trying to get her to eat at all costs and on the flip side, or aggravating her IBD/arthritis during bowel movements (she has not peed/pooped since she has been home).

 

[Red & Rover (GA)]

Tagging
@tiffmaxee
@Wendy&Neko
regarding poss. pancreatitis and for bupe dosing advice. Also IBD/arthritis.

Some reading for you re: pancreatitis
A Primer On Pancreatitis

 

[JL and Chip]

Glad to see your update. I’ve been thinking about you all day.

You might want to review the Pancreatitis Primer located here: https://www.felinediabetes.com/FDMB/threads/a-primer-on-pancreatitis.83108/

It has a lot of valuable info and is well worth a read. I dealt with chronic pancreatitis in Charlie and it could be a reaaaally rough ride until we got a handle on it. SubQ fluids, anti-nausea meds, and pain meds were the magic combination. And syringe feeding, if needed (but only after anti nausea meds were on board). Back then we used subQ fluids daily plus famotidine (Pepcid AC) for nausea and buprenorphine for pain. These days Ondansetron is favored over famotodine.

It’s really good that they send you home with Ondansetron, bupe, and fluids. Too bad, though, that the didn’t run a snap FPL test or send off an fPLI to a lab so you’d have a confirmed diagnosis.

As for triggering the IBD, that’s tricky. Charlie had IBD too. Eating is important to avoid hepatic lipidosis and DKA, so however you can “thread the needle” and entice her to eat without totally blowing up the IBD is likely best. I knew how far I could generally push things with Charlie, so I might gamble and add just a niblet of this or that to his regular food to get his attention — but every cat is different. Charlie’s IBD manifested as massive, explosive, uncontrollable diarrhea which could last for weeks, and of course that dehydrated him which made things worse. It’s a bit of a dance. So like I said, every cat is different; I had to trial and error my way through it.

 

[tiffmaxee]

I am just seeing this now so sorry I did not see it sooner. I’ve not seen a fever with pancreatitis so it’s good they did a culture to see if there’s a uti what would be the best antibiotic. The quick SNAP test only gives a positive or negative result so if in the gray zone would show negative so it’s good they sent a sample out and it should come back the next day.
Were you given ondansetron for nausea? Sub-q fluids? Pain medication? An appetite stimulant? You would want the nausea under control before starting any appetite stimulant. Cats are lethargic with pancreatitis. I too had bupe for pain. Max was always inappetent with pancreatitis but never had diarrhea. He did not have IBD though so I fed him whatever he would eat. Baby food sometimes worked when nothing else did and was also easy to syringe or finger feed.

As for when to hospitalize if you are able to get enough food in, close to 3/4 of normal, and can medicate you can manage at home. Max had chronic pancreatitis and was only hospitalized fur one night over several years. Tiffany had to spend several days in the hospital with acute pancreatitis more than once but she also had lymphoma.

 

[JL and Chip]

They stopped her fluids around ~6PM tonight and I have a bag from urgent care (assuming I can do this at 6PM tomorrow?).

Related to above...do I wait 24 hours to give a large dose of fluids?

How much are they recommending you give and how often? My IM vet would always have me wait until the next day to start subQ. And even though some vets will tell you that you can give a large volume all at once, you want to be careful if there’s any chance of heart problems. My vet and I would often opt to err on the side of caution and split the subQs up into two sessions daily (75-100ml per session depending on the target goal).

 

[Wendy&Neko]

Can I give her Bupe with these other medications?

Definitely can give bupe with ondansetron and Cerenia - that was part of Neko's regular day. I haven't seen contraindications with Clavamox and Mirataz too - hope they gave you the transdermal and not the mirtazapine pills. With the antibiotic, I'd also add a probiotic, given a couple hours apart from the antibiotic. I'd assume she'd be on probiotic of some sort with IBD anyway.

I haven't seen her drink water yet and we have been home about 3 hours.

She had fluids all day at the clinic, might not need it yet. I'd just water down her food that you are going to assist feed.

 

[hellolucy]

My brain feels broken - just got back from taking Lucy back to the ER. She was not moving much, not interested in food this morning (I did assisted feeding ~3AM last night and this morning). She peed once when she got home yesterday and finally again at 10AM this morning. Sure enough, Ketostix registered a small amount of ketones. Waiting for the ER Dr. to call. I am terrified. Is there anything I should be asking the Dr. about/making sure they do in this case besides the usual (fluids and the like)?

 

[Wendy&Neko]

Test her electrolytes in her blood. Hoping they are fine and this isn't DKA yet.

More information in this post, including a link at the bottom on treating DKA should it be that:
Ketones, Ketoacidosis, and Diabetic Cats: A Primer on Ketones

 

[hellolucy]

Test her electrolytes in her blood. Hoping they are fine and this isn't DKA yet.

The vet finally called back after a few hours - they said she doesn't look like she feels great and ketones are elevated from their last test, nothing severe but vet did say concerning. Apparently, they did not test her ketones yesterday before releasing her because 'they thought she didn't need it' which almost seems negligent to me and just assumed they would as it was listed on the pre-bill they sent. I am so frustrated with that and myself for not realizing they did not do so. Ketones the day prior to that were negative and at home before I brought her in so at least there's some baseline to work with. They also said urinalysis results came back and as it turns out, she does not have a UTI. So unsure of why her urine smelled so strongly and/or why her fever was high. They are doing an electrolyte panel along with kidneys, etc. on her and pushed her to the front of the line for an ultrasound today. They said they want to give her fluids/etc. to see if that helps her eat before moving on to tube feeding. They are saying I may be able to pick her up ~18 hours from now (mid tomorrow morning) but I honestly don't feel comfortable doing so at this point. Took her to urgent care Sunday, then in to ER Monday night, out from ER last night, and back in to ER today.

 

[JL and Chip]

urinalysis results came back and as it turns out, she does not have a UTI. So unsure of why her urine smelled so strongly

Some cats will hold their urine when they’re at a clinic or not feeling well, and the old/stagnant urine can be pungent. Same can be true for urine from a dehydrated cat. So maybe it was just something like that.

As long as she’s back at the ER, I might push for a fPLI test for pancreatitis. Even though they’re planning an ultrasound, my IM vet would do both.

 

[hellolucy]

Some cats will hold their urine when they’re at a clinic or not feeling well, and the old/stagnant urine can be pungent. Same can be true for urine from a dehydrated cat. So maybe it was just something like that.

This is good to know. I am happy she does not apparently have a UTI/other complicating factor that we know of.

As long as she’s back at the ER, I might push for a fPLI test for pancreatitis. Even though they’re planning an ultrasound, my IM vet would do both.

I will be asking for it.

At this point, I am just accepting the fact she probably needs to stay multiple nights and the cost is what it is. Just a tough swallow after all the urgent care/vet visits over the past 2 months as well. In the double digits in 3 days but the back and forth is killing me and am sure making Lucy miserable too. I digress...rough!

 

[hellolucy]

Update from the vet: ultrasound shows moderate pancreatitis. Her fever spiked and was 104.5 when she was brought in. Urine culture was confirmed negative so they are unsure of source of infection. She had a tooth abscess a month ago and has been pawing at her mouth since then so am worried it's a dental issue but with her current state, she cannot be put under anesthesia. They said it looked like things were not moving very well via the ultrasound and would be giving her medicine to help her stomach contract. Protein was high.

 

[Diane Tyler's Mom GA]

The vet finally called back after a few hours - they said she doesn't look like she feels great and ketones are elevated from their last test, nothing severe but vet did say concerning. Apparently, they did not test her ketones yesterday before releasing her because 'they thought she didn't need it' which almost seems negligent to me and just assumed they would as it was listed on the pre-bill they sent. I am so frustrated with that and myself for not realizing they did not do so. Ketones the day prior to that were negative and at home before I brought her in so at least there's some baseline to work with. They also said urinalysis results came back and as it turns out, she does not have a UTI. So unsure of why her urine smelled so strongly and/or why her fever was high. They are doing an electrolyte panel along with kidneys, etc. on her and pushed her to the front of the line for an ultrasound today. They said they want to give her fluids/etc. to see if that helps her eat before moving on to tube feeding. They are saying I may be able to pick her up ~18 hours from now (mid tomorrow morning) but I honestly don't feel comfortable doing so at this point. Took her to urgent care Sunday, then in to ER Monday night, out from ER last night, and back in to ER today.

@Wendy&Neko

 

[Diane Tyler's Mom GA]

Update from the vet: ultrasound shows moderate pancreatitis. Her fever spiked and was 104.5 when she was brought in. Urine culture was confirmed negative so they are unsure of source of infection. She had a tooth abscess a month ago and has been pawing at her mouth since then so am worried it's a dental issue but with her current state, she cannot be put under anesthesia. They said it looked like things were not moving very well via the ultrasound and would be giving her medicine to help her stomach contract. Protein was high.

I'm so sorry you both are going through this , sending prayers for Lucy and you. I pray things will get better ♥
Tagging @Wendy&Neko

 

[hellolucy]

Vet just called and said her temp has increased to 106.7 and she is still very sedate/not eating. They are starting her on a second antibiotic. They told me I don't need to come in and to 'get some sleep tonight' but wow, I am so scared with that update.

 

[JL and Chip]

Sending positive vibes your way. I can understand your fear and just wanted you to know someone is out here reading your updates and thinking about you.

 

[Diane Tyler's Mom GA]

Just want you to know we are thinking about Lucy and praying for her ♥

 

[hellolucy]

Sending positive vibes your way. I can understand your fear and just wanted you to know someone is out here reading your updates and thinking about you.

Just want you to know we are thinking about Lucy and praying for her ♥

Thank you both! Another sleepless night, but her fever broke this morning around 8AM thank goodness. I got to spend an hour with her in a quiet room today. Brought her favorite blanket and brush. She still seems incredibly run down (at least from my perspective to her normal self, I'm assuming some of that is being exhausted) but the vet says she is doing better than yesterday. They thought she was 'close' at that point in time so fever breaking and her at least moving around a bit is an improvement I will take. She still is not interested in eating, hopefully that changes. I brought some food from home. No ketones as of this morning. They did a chest x-ray on her today as they said her breathing had sped up but also said that could be because of the fever. They are doing more labs as well. I was pretty firm with them that I needed to understand why this was happening and spiraling as I feel like I've been a bit rushed through the whole time. They think it is an infection but aren't sure of the source. I am wondering about dental issues due to her random mouth abscess a month ago. Doctors said they have all thoroughly checked her mouth and don't see anything but that doesn't necessarily mean an infection is not present. They put her on a second heavy duty antibiotic last night when her fever peaked so will see if that helps. Waiting for the Doctor to call this afternoon with results of x-rays/bloodwork and will be going back in to see her later again.

Are there any other tests I should be asking them to run? I don't know if there is something that can specifically identify an infection besides urinalysis for UTI which she did not have.

 

[Diane Tyler's Mom GA]

Thank you both! Another sleepless night, but her fever broke this morning around 8AM thank goodness. I got to spend an hour with her in a quiet room today. Brought her favorite blanket and brush. She still seems incredibly run down (at least from my perspective to her normal self, I'm assuming some of that is being exhausted) but the vet says she is doing better than yesterday. They thought she was 'close' at that point in time so fever breaking and her at least moving around a bit is an improvement I will take. She still is not interested in eating, hopefully that changes. I brought some food from home. No ketones as of this morning. They did a chest x-ray on her today as they said her breathing had sped up but also said that could be because of the fever. They are doing more labs as well. I was pretty firm with them that I needed to understand why this was happening and spiraling as I feel like I've been a bit rushed through the whole time. They think it is an infection but aren't sure of the source. I am wondering about dental issues due to her random mouth abscess a month ago. Doctors said they have all thoroughly checked her mouth and don't see anything but that doesn't necessarily mean an infection is not present. They put her on a second heavy duty antibiotic last night when her fever peaked so will see if that helps. Waiting for the Doctor to call this afternoon with results of x-rays/bloodwork and will be going back in to see her later again.

Are there any other tests I should be asking them to run? I don't know if there is something that can specifically identify an infection besides urinalysis for UTI which she did not have.

@Wendy&Neko
@Marje and Gracie

Also posting her other thread
https://felinediabetes.com/FDMB/thr...ays-with-no-end-in-sight.286245/#post-3148798

 

[Marje and Gracie]

Thank you both! Another sleepless night, but her fever broke this morning around 8AM thank goodness. I got to spend an hour with her in a quiet room today. Brought her favorite blanket and brush. She still seems incredibly run down (at least from my perspective to her normal self, I'm assuming some of that is being exhausted) but the vet says she is doing better than yesterday. They thought she was 'close' at that point in time so fever breaking and her at least moving around a bit is an improvement I will take. She still is not interested in eating, hopefully that changes. I brought some food from home. No ketones as of this morning. They did a chest x-ray on her today as they said her breathing had sped up but also said that could be because of the fever. They are doing more labs as well. I was pretty firm with them that I needed to understand why this was happening and spiraling as I feel like I've been a bit rushed through the whole time. They think it is an infection but aren't sure of the source. I am wondering about dental issues due to her random mouth abscess a month ago. Doctors said they have all thoroughly checked her mouth and don't see anything but that doesn't necessarily mean an infection is not present. They put her on a second heavy duty antibiotic last night when her fever peaked so will see if that helps. Waiting for the Doctor to call this afternoon with results of x-rays/bloodwork and will be going back in to see her later again.

Are there any other tests I should be asking them to run? I don't know if there is something that can specifically identify an infection besides urinalysis for UTI which she did not have.

If she’s not eating, they need to keep an eye on her liver enzymes because anorexia can cause hepatic lipidosis. I hope she starts to feel better soon.