Plus-Hex CLINICAL
Other considerations
Potassium
Panciera [ 9 ] suggests that almost all patients with DKA will have a total body potassium deficit , and states that hypokalaemia is present in 30 – 45 % of dogs and 55 – 67 % of cats before treatment . Potassium is lost through urine as a result of osmotic diuresis due to increasing glucose levels , decreased renal tubular reabsorption ( as a result of insulin deficiency ) and gastrointestinal losses . Further potassium is lost once insulin is administered as part of the therapy , as it causes a shift of potassium into cells , further exacerbating the hypokalaemia . IVFT will dilute the potassium in the plasma , so hourly monitoring must be carried out to detect this . Potassium supplementation is an essential component of treatment once insulin administration begins . Hypokalaemia can cause muscle weakness , impaired renal function and arrhythmias .
Phosphate
As phosphate moves into the cells alongside potassium , the remaining phosphate is diluted with IVFT , resulting in further depleted levels . Galloway [ 2 ] states that hypophosphataemia occurs in these patients 12 – 24 hours after starting therapy . Intravenous haemolysis , which is life-threatening , is seen when phosphate levels are inadequate . Muscle weakness , seizures and depression can also occur when phosphate levels are depleted [ 10 ] . If supplementation is required , it must be given in calcium-free fluids to prevent the crystallisation of calcium phosphate [ 5 ] . Panciera [ 9 ] states that hypophosphataemia is present in 13 – 48 % of cats and 29 % of dogs with DKA , so it is less common than hyperkalaemia .
Bicarbonate
As acidosis is corrected with the administration of IVFT and insulin therapy , bicarbonate supplementation is not necessarily needed . However , Vets Now [ 6 ] advises assessing acid – base and electrolytes every 4 – 6 hours to support this . Galloway [ 2 ] suggests that if the pH of arterial blood remains < 7 an hour after starting the administration of IVFT , then bicarbonate supplementation should be considered . If bicarbonate levels are unknown , it is strongly advised not to administer it as this could result in serious deterioration . Adverse effects of bicarbonate administration include worsening of hypokalaemia , a delay in the reduction of ketones and a delay in the reduction of lactate [ 5 ] .
REFERENCES
1 Gear R . Medical disorders of dogs and cats and their nursing . In : Cooper B , Mullineaux E , Turner L . ( eds .) BSAVA Textbook of Veterinary Nursing . 6th ed . Gloucester : BSAVA Publications ; 2020 . p . 563 – 566 .
2 Galloway P . Management of feline diabetic ketoacidosis . In : Proceedings of the 38th World Small Animal Veterinary Congress . 2013 . Available from : https :// www . vin . com / doc /? id = 5709925 [ Accessed 22 May 2020 ].
3 Tabor B . Understanding and treating diabetic ketoacidosis . VetFolio . Available from : https :// www . vetfolio . com / learn / article / understanding-and-treating-diabetic-ketoacidosis [ Accessed 19 May 2020 ].
4 Kaneko JJ . Carbohydrate metabolism and its diseases . In : Kaneko JJ , Harvey JW , Bruss ML . ( eds .) Clinical Biochemistry of Domestic Animals . 6th ed . Burlington : Academic Press ; 2008 . p . 45 – 80 .
5 Niessen S . Improving success rates when treating diabetic ketoacidosis . Vet Times . 2011 . Available from : https :// www . vettimes . co . uk / app / uploads / wp-post-to-pdf-enhanced-cache / 1 / improvingsuccess-rates-when-treating-diabetic-ketoacidosis . pdf [ Accessed 23 May 2020 ].
6 Vets Now . Supporting the emergency and critical care patient . Unit 2 , outcome 2 : Nursing the critical patient . [ Unpublished lecture notes .]
7 Wikivet . Diabetic ketoacidosis . Available from : https :// en . wikivet . net / Diabetic _ Ketoacidosis [ Accessed 19 May 2020 ].
8 Jivan D . Management of diabetic ketoacidosis . Journal of Endocrinology , Metabolism and Diabetes of South Africa . 2011 ; 16 ( 1 ): 10 – 14 . Available from : https :// doi . org / 10.1080 / 22201009.2011.10 872247 .
9 Panciera DL . Fluid therapy in endocrine and metabolic disorders . In : DiBartola SP . ( ed .) Fluid , Electrolyte , and Acid-Base Disorders in Small Animal Practice . St . Louis : Elsevier ; 2012 . p . 500 – 513 .
Further reading
1 Dhatariya K , Corsino L , Umpierrez GE . Management of diabetes and hyperglycemia in hospitalized patients . In : Endotext [ Internet ]. 2017 . Available from : https :// www . ncbi . nlm . nih . gov / books / NBK279093 / [ Accessed 28 May 2020 ].
2 MedlinePlus . Osmotic diuresis . Available from : https :// medlineplus . gov / ency / article / 001266 . htm [ Accessed 28 May 2020 ].
3 Zerrenner D , Peterson D , Crawford MA . The evolution of insulin therapy . Compendium . 2007 ; 29 ( 9 ): 522 – 536 . Available from : https :// www . vetfolio . com / learn / article / the-evolution-of-insulin-therapy [ Accessed 28 May 2020 ].
Conclusions
Patients with DKA must be treated urgently as they are often seriously ill and may present collapsed , dehydrated and hypovolaemic . They may be anorexic and may present with electrolyte abnormalities and acidaemia .
Volume 38 ( 5 ) • October 2023
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