? New Member - Out of remission and into DKA, looking for advice

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Rebecca M

Rebecca M

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Hi everyone - I'm new here and just desperate for thoughts, advice, answers. I love my cat more than anything but clearly have not taken his diabetes seriously because I've made a serious of rookie mistakes multiple times now, and I need guidance.

I'm so sorry for how long this is but I don't know which information is important and I don't want to leave anything out.

My cat, Yahiko (male, 15) has been diabetic twice before, and twice before he went into remission after being on only Fancy Feast. I had an AlphaTrak 3 glucometer that was giving really wild and inconsistent readings and I had to prick him multiple times to get blood out of him, which he hated and he is a BIG cat (healthy body weight for his size is 15.5 to 16 lbs - massive, and when he was first diagnosed with diabetes he was overweight at 18.5) so it was really difficult to hold him and get a reading. The vet said as long as he was doing okay, it was fine, and the freestyle Libre they gave either didn't take or I don't know what but the readings on it were WILDLY different - I would take it 4 times in a row, like within 1-2 minutes, and get numbers from the 60s to 200s even in the middle of the day or before eating. So we didn't replace it. Last time he went into remission, we had no idea and were giving him Lantus (1 unit every 12 hours) and he had a seizure one morning; this was about 7 or 8 months ago. He went off insulin. As with last time, he was able to maintain remission with just the Fancy Feast diet and the occasional treat here and there.

Here's where I messed up. He developed IBD and was losing weight due to malabsorption. They put him on a steroid, budesonide, specifically because it's good at not impacting blood sugar in cats. In October we realized he needed a tooth pulled (it wasn't infected yet but was at risk of it and was super inflamed) and we wanted to get some weight back on him before the surgery because he was at his lowest and was just not healthy, so we planned to put it off for a couple of months and we reintroduced a small amount of dry food. Diabetes was the furthest thing from my mind because of the remission, the upcoming surgery, etc. We very abruptly needed to move his surgery up to November 20 to remove a small mass on his abdomen (suspected mammary tumor, turned out to be a cyst), so for the week and a half until that point, we gave him more dry food. He gained weight at a reasonably healthy rate and it was still low at something like 13 pounds and he was still a little bony but it was better.

I missed a million warning signs over the course of about a week. He was hiding away behind our Christmas tree - I thought because he was healing from surgery. He was drinking a lot, but that can be normal for him even in remission (he has between stage 1 and stage 2 kidney disease, diagnosed earlier this summer around the same time as he went into remission). He stumbled a couple of times and I took note but thought maybe he was just off-kilter because he was still eating normally. Like I said, stupid mistakes. Sunday, December 10, I left for a one week work trip. Tuesday, December 12, my roommate/best friend messaged me after the cats ate dinner and told me she was worried because he'd barely eaten that morning or in the evening and was clearly hungry but doing "weird stuff with his mouth". I immediately assumed an infection from the tooth removal and told her to bring him to the vet. She did the very next morning - where they found his blood sugar was 619 and he was in DKA.

I flew home immediately while he was admitted to the ICU. My cat is extremely anxious and stubborn and was not doing well - the vet was giving me between 60-70% survival chance on the phone that morning but by the evening the night vet was much more guarded. He perked WAY up for me and ate a little bit as soon as I got there. (This is honestly normal for him - I have 6 cats but he is the only one who is like this around me, an absolute momma's boy.) So she was much more optimistic and told me that the ones who eat even at the beginning of treatment tend to fair better.

The morning vet called me at 8AM the next morning (yesterday) telling me she didn't think he was doing well. He was laying there, too weak to lift his head, and his potassium was low. I rushed over thinking we were about to euthanize. But once again, he shocked ALL the nurses and vets by immediately popping up and coming over to me when I sat down in front of him. He laid half in my lap and they wouldn't let him eat because he had an ultrasound but he clearly wanted to and drank. They gave him a potassium supplement and it got up to 3.3 (I think it was at like 1.8 before that - it was very low). They took him off the insulin drip and put him on 4 hours of the highest safe dose of potassium. I went to see him in the afternoon and he was MILES better, so much so that the same vet who was gently encouraging me to euthanize told me he was absolutely trending upward and began talking about long-acting insulin. His potassium went up to 3.3 (though his blood glucose, which had gone down to 280, was back up to 340), his ultrasound was completely clear, he was SO alert and perky and moving around and demanding more food/treats, it was great.

They wanted me to come back at 8:30PM to feed him and bring Lantus with me (they didn't have any, I had to go pick up a prescription). I did so but they had multiple emergencies and told me to come back later, so I came back around 10:45. They told me he had eaten a little around 9 (which was the idea; they wanted him on 9 to 9 to start the Lantus); for me he ate a ton, which was great, but because of that they decided not to do the Lantus until the morning at 9 because they want him on a regular schedule. But I could tell he was off. He was more lethargic and clearly wanted to come to me but couldn't get himself up on his hind legs. I asked if his potassium could have dropped and all 4 of them said no, they didn't think so, but I pressed a little harder and they processed his bloodwork and it turned out that yes, it had dropped to 2.5. They added more potassium to his IV. That vet (last night) was EXTREMELY optimistic. She was talking about diet when he comes home (to manage the kidney disease and diabetes and potentially the IBD if it's still there - they saw no evidence on ultrasound but unclear) and said his prognosis was "really, really good". I was so upset that his potassium had dropped but she was unphased and said it was normal because of the CPI(?) insulin drip which is why they were wanting to wean him off and switch him to Lantus.

I left around midnight and arrived this morning at 8:30AM to feed him per her instructions. It turned out they tried to feed him themselves and he actually ate an entire meal for them, which is amazing, and they gave him the Lantus right before they brought him to me. This time they put me in a new room with him, and he was walking around quite a bit (though very weak, stumbling a bit, etc) but I don't honestly know if that was because he had a lot of energy or if it was because he was scared and there wasn't a place for him to lay down comfortably on the hard floor. He drank a ton of water when we offered it and he wanted pets and kept going to the doors to try to escape LOL. I was feeling okay about it, not great, but the vet that came in this time was so much more guarded that it REALLY threw me off and I have no idea what to think. By now he's been in the ICU about 48 hours. She said that his blood glucose had gone up overnight to 380 but that that was to be expected because he kept eating and they were weaning him off the CPI. They got his potassium up to 3.1 and are continuing with IV and oral supplements. But she was being very, very guarded and just kept warning me that whether or not he'll be able to stabilize is a giant question mark and that he may never be able to self-regulate enough to come home.

I'm just so baffled (and obviously feel so guilty because this is 100% my fault and was completely preventable). We've seen 4 vets and it's been a complete yoyo of an experience. The first said good prognosis, the second was essentially telling me he wouldn't survive but then did a complete 180 by the end of the day, the 3rd was super optimistic, and the 4th (8 hours after the 3rd) sounds like she's telling me I shouldn't be expecting him to survive. I feel like if he's JUST started the Lantus and he's responded well to it in the past, and if it's just a matter of getting his potassium back up because everything else is great (and his vitals have been completely stable since he arrived), the prognosis should be good, like last night's vet said. But I can't get this vet's words out of my head and I'm absolutely distraught. She was there yesterday morning when he wasn't doing well and kept referenсing that and how he's still doing better now because yesterday morning he didn't want to be alive. But I also kept explaining to all of them - and everyone except her agreed with me by the end of the day yesterday - that this is NOT a normal cat. None of my other cats would act like this but he is extremely anxious and I am his lifeline. He went from "euthanize, he can't move" to walking around, meowing, eating in 60 seconds as soon as he saw me. So I don't know if she's just trying to play devil's advocate or if she's jaded after yesterday morning or if all of the other vets have been overly optimistic and he's actually still in really dire straights and there's a good chance he won't survive.

I know there are so many incredible experts and people who have been through this on this forum. Could anyone please give me your best interpretation, and also your best guidance? Should I be assuming he won't make it and hold off on any long-term plans? Does it seem like he's moving in the right direction and I should be looking at home glucose monitors? If so, which one do I start with? What do I need to look out for to tell if he's getting better or worse in the ICU?

I'm so confused and I'm so devastated. I'm grateful for any amount of time you can spare to give me your experience, opinions, guidance, etc. I'm scared to ask the ICU vet because I get a different answer each time and it's making it so hard for me to actually gauge where we're at.
 
I am reading through your message and I can really relate. This sounds similar in many ways to what I went through with my Darcy when he went into DKA. First of all, throw that guilt away, at least for the time being, because it will not help your boy and it will not help you to deal with everything.

Second, DO NOT GIVE UP! DO NOT GIVE UP! I went through the same thing with my boy in DKA (he also got hepatic lipidosis and had to have a feeding tube for a while.). We had different vets every day and frequently a different vet from the early part of the night to the morning hours. I got differing levels of optimism and pessimism depending upon the vet. Our emergency vet os only open on weekends/holidays and on a regular weekday you have to come at 7:30 a.m. and pick up your animal and transport them to your regular vet. So every weekday morning, I picked Mr. Darcy up and took hi to my regular vet. Every evening I took him back to the Emergency Vet facility which had different vets each day/shift. But he also improved whenever he saw us. I actually think that some of the transportation back and forth was rough on him, but when he was with us in the car, he REALLY perked up. I was very discouraged and afraid after a few days about whether he would ever recover. One of the overly presumptuous vet techs told me that “this cat is not going to get better “ and she offered to euthanize him for me!” I was so upset. So DO NOT GIVE UP! MY cat was in the ER and regular vet during weekdays for a total of 9 days. He made it. In his case, he needed the feeding tube. Your boy needs you, it sounds like.
 
I’m sorry your baby has been so sick. I echo Suzanne’s comments. We’ve seen some seriously ill kitties with DKA that have pulled through.

Most important is getting the electrolytes balanced, getting lots and lots of calories in him, fluids, and keeping his BG in a better range. I couldn’t tell what insulin they started him on but normally they would give him a more short-acting insulin like Humulin R (“R”) or Humulin N (“N”). They can give these more often and they act quicker than Lantus.

However, it sounds like they now have Lantus on board. The issue with Lantus is it takes several days to build up the depot and have a positive effect on the BG.
Very experienced vets can give Lantus as the basal insulin and give the R as a bolus. We have helped members do that here in some situations.

It is difficult to be dealing with multiple vets. Getting through DKA can take many days in the hospital. The fact that he’s eating is excellent as many of these cats do not and, as Suzanne said, must have a feeding tube. He needs to be getting 2-3 times his normal amount of calories so it might be necessary to talk to the vet about whether a feeding tube would help.

We all hope he starts to do much better. Yes, you will need a human glucometer when he comes home and you will need to stay on top of the testing. You’ll also need urine ketone strips or, better yet, a blood ketone meter which are not expensive and work basically the same as the glucometer. It will take some nursing so you can be sure he continues to eat well and get fluids by mouth. At this point, it’s most important that he eats a lot of calories so it doesn’t matter what he eats as long as he eats although better that he eat high calorie canned food, if possible.

I hope that helps.
 
My kitty was a DKA survivor. I had two vets -- mine and the vet at the emergency hospital -- tell me that many cats don't survive. Mine did. Like others said, don't give up. It doesn't sound like your kitty has given up.

I don't know if this was an oversight, but do you know if the vet is doing basal/bolus dosing of insulin. What this means is that they will use a longer acting insulin (it could be Lantus) coupled with a fast acting insulin (e.g., "regular" insulin -- Humulin R or Novolin R) to keep your cat's blood glucose in a lower range. As Marje noted, Lantus takes a while to build up in your cat's system. It also sounds like they are not giving insulin on a strict 12-hour schedule. I would definitely talk to the vet about basal/bolus dosing. Also, blood glucose levels should be monitored for a slow change. Too fast of a drop in BG levels could cause changes in osmolality (i.e., water - electrolyte balance).

Is there an infection? If so, your cat needs antibiotics. The basic recipe for ketones is not enough insulin + an infection/inflammation + not eating. It sounds like Yahiko is eating and drinking which is great. Dehydration is common. Make sure your cat is getting enough fluids. Mine was on IV fluids.

Electrolyte imbalance is a major issue with DKA. Your cat is in metabolic acidosis. The electrolyte levels can change quickly. In addition to potassium levels, your vet needs to be checking sodium and phosphorus levels. (These are usually part of a normal electrolyte panel.) Some cats also have alteration in magnesium levels. Your vet should be running labs at least twice a day.

I'm attaching a summary of a DKA presentation from a veterinary conference. It's older but it is a good overview. The downside is that the author is from New Zealand so some of the drug names are not the names we use here and they didn't include the generic name (e.g., I haven't a clue what Actrapid is other than it's a fast acting insulin).

One other practical suggestion. Since your cat is a momma's boy, you might want to bring a smelly t-shirt to keep in his cage. A familiar smell may be comforting for him.
 
Thank you all SO so much. Yesterday a vet tried, first subtly and then outright, to tell me to euthanize him, but then last night she completely switched gears and said he looked like a new cat and she wants to send him home today. And I am THRILLED about that - in theory. But also really scared/worried.

His potassium has been up and down. He's been off the insulin drip for about 24 hours and they've been steadily increasing his potassium. It was a 4 when he was discharged, went down to a 1.8(!!!) after the first full day of the IV insulin, they turned the insulin off and put him on a 4-hout IV of potassium and got him up to 3.3. He's been up and down since then, still receiving potassium in IV and oral supplements. Yesterday morning it was 2.8 but he had no clinical signs so they increased oral but not IV. After his Lantus last night, it's only increased to 2.9, so the vet is now increasing his IV amount too.

His blood glucose is down to I think 295 she said? Or 245? It's been wavering in the 200s. He's on a freestyle libre now. She didn't increase his Lantus because she wanted to follow the curve, so he's still getting only 1 unit with each meal.

What's really scary for me, though, are the ketones. The overnight vet did warn me that the strips can be inaccurate but she said the urine glucose/ketones are 500(??? Are those the same thing? I'm really confused but that's a high number and she said it hasn't changed - I haven't been told this number yet so I have no reference). Does that mean he is still in ketosis and/or still at risk of slipping back into DKA? I want him home but he's only been hospitalized for just under 3 days (about 70 hours). I bought ketone strips but I don't actually know what I'm supposed to do with them because if I'm understanding how to use them correctly, the numbers he has a the vet right now would prompt me to BRING him to the vet, but they want me to bring him home. And I can't test potassium at home - that terrifies me because what if it drops again because of the Lantus and no longer having the IV K supplement??

Thank everyone IMMENSELY for your answers and your support and just everything. I'm in tears just reading them. If anyone has any thoughts/experience with the potassium stabilization and acceptable urine glucose/ketone(???) I'm all ears. I'm trying to decide if I push for him to stay another day or if I take him home because these are normal and he'd recover better there.
 
Have they been updating you daily with bloodwork? I got copies for myself every day of Darcy’s bloodwork and the ER emailed the bloodwork to my vet and vice versa — back and forth every day.

Electrolytes definitely must be monitored closely as Sienne said. When Darcy was hospitalized, one day his potassium went sky high, which is very dangerous and required all night monitoring and administration of insulin to bring it down.
I don’t want to overwhelm you, but here is a link to a World Small Animal Veterinary Association conference in 2013 — it’s on the management of DKA in cats.
https://www.vin.com/apputil/content/defaultadv1.aspx?pId=11372&meta=Generic&id=5709925
 
Sienne and Gabby (GA) said:
My kitty was a DKA survivor. I had two vets -- mine and the vet at the emergency hospital -- tell me that many cats don't survive. Mine did. Like others said, don't give up. It doesn't sound like your kitty has given up.

I don't know if this was an oversight, but do you know if the vet is doing basal/bolus dosing of insulin. What this means is that they will use a longer acting insulin (it could be Lantus) coupled with a fast acting insulin (e.g., "regular" insulin -- Humulin R or Novolin R) to keep your cat's blood glucose in a lower range. As Marje noted, Lantus takes a while to build up in your cat's system. It also sounds like they are not giving insulin on a strict 12-hour schedule. I would definitely talk to the vet about basal/bolus dosing. Also, blood glucose levels should be monitored for a slow change. Too fast of a drop in BG levels could cause changes in osmolality (i.e., water - electrolyte balance).

Is there an infection? If so, your cat needs antibiotics. The basic recipe for ketones is not enough insulin + an infection/inflammation + not eating. It sounds like Yahiko is eating and drinking which is great. Dehydration is common. Make sure your cat is getting enough fluids. Mine was on IV fluids.

Electrolyte imbalance is a major issue with DKA. Your cat is in metabolic acidosis. The electrolyte levels can change quickly. In addition to potassium levels, your vet needs to be checking sodium and phosphorus levels. (These are usually part of a normal electrolyte panel.) Some cats also have alteration in magnesium levels. Your vet should be running labs at least twice a day.

I'm attaching a summary of a DKA presentation from a veterinary conference. It's older but it is a good overview. The downside is that the author is from New Zealand so some of the drug names are not the names we use here and they didn't include the generic name (e.g., I haven't a clue what Actrapid is other than it's a fast acting insulin).

One other practical suggestion. Since your cat is a momma's boy, you might want to bring a smelly t-shirt to keep in his cage. A familiar smell may be comforting for him.
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I went to the vet straight off the plane and gave him the shirt I was wearing, and every time I have visited him since then I have brought him a new one and a towel! His kennel is FULL of my clothing right now LOL.
 
Suzanne & Darcy said:
Have they been updating you daily with bloodwork? I got copies for myself every day of Darcy’s bloodwork and the ER emailed the bloodwork to my vet and vice versa — back and forth every day.

Electrolytes definitely must be monitored closely as Sienne said. When Darcy was hospitalized, one day his potassium went sky high, which is very dangerous and required all night monitoring and administration of insulin to bring it down.
I don’t want to overwhelm you, but here is a link to a World Small Animal Veterinary Association conference in 2013 — it’s on the management of DKA in cats.
https://www.vin.com/apputil/content/defaultadv1.aspx?pId=11372&meta=Generic&id=5709925
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Yes, I ask obsessively to the point where I'm pissing some of them off and I have my own little table of his values etc to try to keep track of them all. The Lantus seems to be quickly bringing his BG to a healthy level but it's suppressing the potassium. Creatinine pretty steadily decreasing but will probably be a higher baseline (3.3 at first arrival, 2.17 now - hoping for a little more improvement but not likely). Phosphorus was a bit off but normal now.
 
I bought a Nova Max Plus blood ketone meter and test strips from ADW Diabetes Supply. I felt more comfortable getting a blood reading on the ketones instead of stalking him to the litter box and interpreting colors on a strip. Now, I had trouble convincing my vet about the accuracy of these meters. She was unfamiliar with them and didn’t trust them.
 
Rebecca M said:
Yes, I ask obsessively to the point where I'm pissing some of them off and I have my own little table of his values etc to try to keep track of them all. The Lantus seems to be quickly bringing his BG to a healthy level but it's suppressing the potassium. Creatinine pretty steadily decreasing but will probably be a higher baseline (3.3 at first arrival, 2.17 now - hoping for a little more improvement but not likely). Phosphorus was a bit off but normal now.
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Good girl! You are just like me in this respect.
 
I ordered a blood ketone meter last night actually! It will be delivered today. Glad to hear my instincts were right on that one.

Regarding the ketones value not changing - do you have any thoughts? Is that normal? How long should it take to come down and what is an acceptable ketone reading for a cat to be considered safe from slipping back into DKA?
 
Here’s the section on ketone measurement from the document I linked. I am not too sure about those numbers (500?)

Hyperglycaemia, Glucosuria, Metabolic Acidosis Plus Ketones in Plasma and/or Urine

Traditionally DKA has been diagnosed using urinary ketone dipsticks, which detect acetoacetate but not beta-hydroxybutyrate. However as the latter is the principle ketone body in DKA, measuring serum beta-hydroxybutyrate is a more sensitive indicator of DKA. In humans portable meters that measure beta-hydroxybutyrate in whole blood have largely superseded urine dipsticks. These ketone meters have recently proven useful in diagnosing DKA in cats, although they tend to underestimate beta-hydroxybutyrate at higher values (Zeugswetter, Rebuzzi 2012; Weingart et al. 2012). In the absence of a ketone meter, using urine dipsticks to measure plasma ketones is more sensitive than just checking for ketones in urine. A recent study cited a sensitivity/specificity of urine ketone dipsticks as 100/88% for plasma (with a cut off of 4 mmol/L) and 82/95% for urine (with a cut off of 1.5 mmol/L) (Zeugswetter, Pagitz 2009).
 
If he is eating and is properly hydrated and any underlying infection is being treated, I would think that the ketones would come down. That may be another red flag that he is not yet ready to come home? I would ask the vet about this.
 
I will also say (sorry, just thought of this)that my Darcy had high ketones for quite a while after his DKA (I checked every day with the blood ketone meter.). He did fine despite this as long as he was eating and drinking well/staying hydrated (I did do a lot of sub-q fluids at home to try and help with that.). He never had another DKA. It wasn’t until he started getting adequate doses of insulin that his ketones really came down. (That was an edit above — he had acromegaly and so required high doses of insulin— but the point, I guess was that he lived with what would be considered high ketones for a long time and was fine as long as I kept him hydrated and he ate well and he got his insulin.
 
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Just left after our visit and wanted to give an update. The day vet this time (who actually used to work at/co-own his regular vet clinic) agreed with me about keeping him another day. She says best case maybe late tonight, but personally I'm fine with tomorrow and let her know that.

His urine glucose is 500 but his blood glucose was in the 200s. His urine ketones are at 5. He's still in ketosis but no longer acidosis. He ate only about half of a can of Fancy Feast this morning which I didn't love but they've got him on an appetite stimulant so I hope more tonight. She agrees about needing to stabilize his potassium and also wants to see a change in his ketones, so those are the 2 main things. She said she'll probably send him home with ketones in his urine still but she wants to see evidence that they're resolving. So fingers crossed for tomorrow morning - I will take him tonight if they insist (but then I want his potassium to be above a 3.5 and then I will take him back on Monday to his regular vet to test his blood work and see where it's at, so he'll only be unchecked for a day).

I'm going to ask at discharge about subq fluids. I also noticed an insulin smell after she gave it to him this morning so I asked them to keep an eye on it. He's fitted with a freestyle libre right now and I've ordered the ReliOn glucometer based on recommendations here just for backup, I'll use it maybe once a day in the morning to make sure things are looking okay. I have urine test strips for ketones and the meter being delivered today. I feel as prepared as I can be but if anyone sees anything I can or should be adding to my DKA recovery kit, please let me know!!

Also he tested negative for a UTI at intake but a day or two ago one of the vets started him on antibiotics anyway while we waited for a longer culture, and now it turns out he has a bladder infection (which could have helped cause the DKA or could be because for his first 2 days he refused to pee and they had to manually express his bladder). So I'm hoping that once that is resolved, everything will kind of settle into place.
 
When you say you noticed an insulin smell, can you be more specific? Ketones cause a cat's breath smells like acetone (think nail polish remover). Lantus has a distinctive smell -- most people think it smells like bandaids.

Just an FYI -- UTI vs bladder infections vs kidney infections can be challenging to separate out on initial diagnosis. I'm glad they have him on an antibiotic.
 
Sienne and Gabby (GA) said:
When you say you noticed an insulin smell, can you be more specific? Ketones cause a cat's breath smells like acetone (think nail polish remover). Lantus has a distinctive smell -- most people think it smells like bandaids.

Just an FYI -- UTI vs bladder infections vs kidney infections can be challenging to separate out on initial diagnosis. I'm glad they have him on an antibiotic.
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Sorry, realizing that was super vague. She gave it to him and left the room and I smelled it, so I rubbed my fingers in the fur between his shoulder blades and when I pulled them back they smelled like insulin. It wasn't wet, though. She might have just had insulin on her fingers but just in case she missed and it went into his fur (or part of it did), I let them know.
 
Update from the vet - as of 2 hours ago his blood sugar is 196 and his potassium is up to 3.4. They're keeping him on potassium supplementation. He only ate half a can of Fancy Feast this morning and a 7-calorie liquid treat so the insulin really lowered it, which is good but also I would much rather him eat more and the curve be slower so we'll see how he eats tonight. The freestyle libre gave a reading of 250 at the same time the blood test gave 196 so that makes me a little nervous and I'm glad I got the glucometer too. They haven't retested his urine yet so still just kind of going off the 500 glucose/5.0 ketones which is also keeping me pretty anxious but fingers crossed we see good stable numbers this evening
 
Rebecca M said:
Update from the vet - as of 2 hours ago his blood sugar is 196 and his potassium is up to 3.4. They're keeping him on potassium supplementation. He only ate half a can of Fancy Feast this morning and a 7-calorie liquid treat so the insulin really lowered it, which is good but also I would much rather him eat more and the curve be slower so we'll see how he eats tonight. The freestyle libre gave a reading of 250 at the same time the blood test gave 196 so that makes me a little nervous and I'm glad I got the glucometer too. They haven't retested his urine yet so still just kind of going off the 500 glucose/5.0 ketones which is also keeping me pretty anxious but fingers crossed we see good stable numbers this evening
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Well certainly 5.0 on the urine ketones warrants him remaining in the hospital but usually the maximum we see on urine ketone strips is 8. Ideally, it should be 0.5; as long as they keep food, fluids, insulin to bring and keep the BG down, and antibiotics going into him and keep working towards getting all electrolytes back into the normal range, then there is progress.
 
Marje and Gracie said:
Well certainly 5.0 on the urine ketones warrants him remaining in the hospital but usually the maximum we see on urine ketone strips is 8. Ideally, it should be 0.5; as long as they keep food, fluids, insulin to bring and keep the BG down, and antibiotics going into him and keep working towards getting all electrolytes back into the normal range, then there is progress.
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Thank you for this!! It's now been 12 hours since that number but I'm not sure how much progress is reasonable to expect in 12 hours? I'll find out his new value in 2 hours. What urine glucose value would you consider reasonable for going home? I don't ask because I want to rush him out of the hospital but rather because I want to understand what number would be reasonably alarming to push back against if they try to send him home with me tonight.
 
Rebecca M said:
Thank you for this!! It's now been 12 hours since that number but I'm not sure how much progress is reasonable to expect in 12 hours? I'll find out his new value in 2 hours. What urine glucose value would you consider reasonable for going home? I don't ask because I want to rush him out of the hospital but rather because I want to understand what number would be reasonably alarming to push back against if they try to send him home with me tonight.
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I would not focus on what his urine glucose level is. Once the BG has exceeded the renal threshold where glucose is dumped into the urine (this is about 250 mg/dL but varies by cat), it takes a while to clear that glucose out of the urinary system. You might actually test him and find his BG is a normal number but he still has glucose in his urine. More important is to focus on his ketone level, his electrolyte level, and then his BG. If his ketones and electrolytes normalize and he is eating and drinking, you can manage a higher BG at home and the urine glucose is inconsequential.
 
Marje and Gracie said:
I would not focus on what his urine glucose level is. Once the BG has exceeded the renal threshold where glucose is dumped into the urine (this is about 250 mg/dL but varies by cat), it takes a while to clear that glucose out of the urinary system. You might actually test him and find his BG is a normal number but he still has glucose in his urine. More important is to focus on his ketone level, his electrolyte level, and then his BG. If his ketones and electrolytes normalize and he is eating and drinking, you can manage a higher BG at home and the urine glucose is inconsequential.
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Thank you, I really appreciate it. The electrolytes seem to have normalized and he is eating and drinking (though not eating as much as I would like). What ketone level would be reasonable to go home with? It was 5.0 yesterday afternoon and still 5.0 at 5AM this morning (12 hours ago).
 
Rebecca M said:
Thank you, I really appreciate it. The electrolytes seem to have normalized and he is eating and drinking (though not eating as much as I would like). What ketone level would be reasonable to go home with? It was 5.0 yesterday afternoon and still 5.0 at 5AM this morning (12 hours ago).
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You usually want them at trace (5 mg/dL) or lower on a urine ketone test strip. You might find this post helpful. Be sure you are aware of the units on the urine test strips because some can vary. Many only have the colors.
 
Marje and Gracie said:
You usually want them at trace (5 mg/dL) or lower on a urine ketone test strip. You might find this post helpful. Be sure you are aware of the units on the urine test strips because some can vary. Many only have the colors.
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Thank you, I read through it! I'm struggling with how to approach this with the vet (at least today's vet) - she was very firm with me twice now that he will still have keytones when she sends him home and they could take weeks to taper off to normal. Does that mean that he would have to be there for weeks in order to safely come home?

I am definitely not taking him home tonight, though; she said that they only test the urine once a day so the next test won't be until around 5AM tomorrow morning (10 hours from now) and she had told me this morning that she doesn't want him to leave until there's improvement so he's coming home tomorrow (at the earliest, or longer if need be) no matter what, which I'm pleased with. Similarly she said they only test the potassium once every 12-24 hours so I won't have an update on that until early morning, either, since they tested it at 1PM.

I have one more question for you or anyone else who has the time. When this has happened in the past (though never to this degree), I have syringe fed him initially due to the poor appetite. He's eating every time he sees me, but not nearly enough, and they don't let him eat in between his 2 daily meals to regulate his BG. So this morning he ate about 1 half of 1 can of Fancy Feast - probably around ~50 calories at best. He's a big cat and VERY skinny and it's scaring me but they would not let me syringe feed. They're giving him oral potassium supplements which I know can irritate cats' stomachs/make them nauseous, and the other part of the problem seems to be that he has some sores on his lips, especially on one side - so he'll lick away at the liquid part of his meal, but as soon as a "chunk" of anything rubs up against his mouth, it's game over and he stops eating, even though he repeatedly approaches it and I can tell he wants to eat. I syringe fed last night because no one told me not to and now I'm really on the fence. I want food in him so he doesn't starve or go into hepatic lipidosis but she's so adamant about no snacks between meals and he should only eat what he wants to eat. Do I risk pissing off the vet and press the issue?? Am I wrong about his food needs to begin with and I should just go with what she's telling me? I keep seeing posts about cats needing 1.5x their normal calories during DKA recovery. He's getting about 1/3 (.33) his normal calories right now, so even though he's eating, he's still losing weight and also still in ketosis last I knew so probably still burning fat (though there's really none left) like crazy.
 
Rebecca M said:
Thank you, I read through it! I'm struggling with how to approach this with the vet (at least today's vet) - she was very firm with me twice now that he will still have keytones when she sends him home and they could take weeks to taper off to normal. Does that mean that he would have to be there for weeks in order to safely come home?
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I might have spoken too soon on the level of ketones to release them. I believe I saw @Suzanne & Darcy say Darcy still had high ketones when they sent him home. Let’s see if she will see this and she will have the best info.

Rebecca M said:
they don't let him eat in between his 2 daily meals
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Why not?

Rebecca M said:
Do I risk pissing off the vet and press the issue?? Am I wrong about his food needs to begin with and I should just go with what she's telling me? I keep seeing posts about cats needing 1.5x their normal calories during DKA recovery. He's getting about 1/3 (.33) his normal calories right now, so even though he's eating, he's still losing weight and also still in ketosis last I knew so probably still burning fat (though there's really none left) like crazy.
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He’s your cat and you are his advocate. You should tell her he is used to getting more than two feedings a day and you want more calories in him to help him gain weight. If he’s only getting 33% of his normal calories, I would think she would listen to that. Be frank with her that you can’t afford to deal with hepatic lipidosis and that you’ve read up on DKA. If she gets pissed, then she’s not a very good vet. I know it’s easy for me to say but believe me, I’ve been through similar situations where a vet has said one thing and I’ve politely told them I know my cat and since I am his/her advocate, I know need to be a member of the team that makes the decisions. You are paying the bills, after all.
 
About the feeding… you are correct that he needs to eat more, and more frequently. When my cat was in the ER with DKA and after they had placed the feeding tube, they had him on a metered pump kind of thing — to automatically deliver food/calories through the tube to him at a constant rate. When I brought him home, I was given specific instructions to feed him frequently.
 
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