A little sweet, a little sour:

Diabetic Ketoacidosis
Jen Loewen, DVM, DACVECC
Assistant Professor, Western College of Veterinary
Medicine
Objectives

• Recognizing the signs of a DKA

• List predisposing causes
• Treatment of DKA
• Discuss electrolytes to monitor
• Calculate supplementing
• Describe insulin therapy during DKA treatment
Outline
• What is DKA
• Underlying causes
• Diagnosis DKA
• Fluid therapy
• Electrolyte therapy go through calculations for potassium and
phosphorous
• Insulin therapy
What is Diabetic KetoAcidosis?
• D- Blood glucose level

• K- Ketone level

• A- Acidosis
What is Diabetic ketoacidosis?

Insulin deficiency + glucagon increase

• Diabetic emergency

Oxidation of fatty acids

• Ketones → acidemia Ketone production

• Ketonuria and glucosuria → osmotic diuresis
→dehydration and electrolyte derangements
Underlying diseases and insulin resistance
Increases blood glucose (counter regulatory
Decreases blood glucose hormones)
• Insulin • GLUCAGON
• Growth hormone
• Cortisol
• Catecholamines
• Progesterone** (are they intact
females?)

These counter-
regulatory hormones
increase with stressed
or disease states
When should we be expecting DKA?

• ANY SICK DIABETIC

• Not eating well
• Vomiting
• Lethargic
• Diarrhea
• History questions → weight loss with a good appetite, PU/PD,
cataracts in a dog

• Can you smell it???

Underlying disease

Dogs – 71% Cats – 93%

• Pancreatitis • Hepatic lipidosis
• Cushings • Cholangiohepatitis
• Neoplasia • UTI
• UTI • Neoplasia
• Hypothyroid • Pancreatitis
• Pneumonia
Diagnosis
• D- Blood glucose level
• Consider adding a Big4/emerg panel/quat for sick patients
• PCV/TP, blood glucose, Azostick
• K- Ketone level

• A- Acidosis
Ketones

Dip stick Ketometer

• Measures acetoacetate and • Measures B-hydroxybutyrate
acetate but not B-
hydroxybutyrate
• Dogs > 3.5 mmol/L
• If <2.8 unlikely
• Urine or Serum • Cats > 2.55 mmol/L
• If you spin down a PCV/TP or
other blood
Acidosis
• pH <7.3
• Blood gas/istat
• Chemistry panels (TCO2 or bicarb) Most of the CO2 in the body is
bicarb which is why on some
chemistry analyzers it is called
• ** Can be DK (diabetic ketosis)** TCO2

• Not as severe
• Can progress
Additional testing to recommend
• CBC/CHEM/UA
• Urine culture

• Chest radiographs Reason: looking for the underlying disease

• Abdominal ultrasound
• +/- PT/PTT
Treatment
• Life threatening concerns
• Fluid therapy
• Electrolyte derangements
• Acid Base
NOT insulin therapy
Fluid therapy
• Primary goal
• Treat hypovolemia → IMPROVE PERFUSION
• Replace dehydration
• Correct electrolytes
• Correct acidemia
Fluid therapy
• Treat hypovolemia/improve PERFUSION
• Observe for signs of shock

• Total shock dose

• Dog: 90 ml/kg
• Cat: 60 ml/kg
• Administer in ¼ shock boluses
What type of fluid to chose?

• Lactated Ringers Solution

• Norm R
• 0.9% NaCl
What type of fluid to chose?

• Lactated Ringers Solution

• Balanced solution
• Contains Lactate (a buffer, avoid if liver failure)
• Small amount of potassium
• Lower Sodium amount (130 mmol/L)
What type of fluid to chose?

• Norm R
• Balanced solution
• Contains acetate and gluconate (buffers)
• Mildly higher sodium amount than LRS (140 mmol/L)
• Contains a small amount of potassium
What type of fluid to chose?

• 0.9% NaCl
• Not balanced → Na + Cl
• No Buffer → is acidifying
What type of fluid?
• Loewen’s preference
• LRS or Norm R

• Reality
• Giving any of these isotonic fluids to improve perfusion is better than no
fluids in a patient with hypovolemic shock and relatively normal sodium
Fluid therapy
• Remember to include to full fluid plan which includes:
• Maintenance (many equations)
• 2 ml/kg/hr, 40-60 ml/kg/day, BW x 30 + 70 etc…
• Dehydration
• Ongoing losses
• Vomiting, diarrhea, PU?
MUST REASSESS!!!
Fluid therapy
• Replace dehydration
• Come up with your % based on PE/Hx

• Ex 5 kg cat with 8% dehydration (poll)

MUST REASSESS!!!
Fluids alone will:

• Improve perfusion → decreased lactate

• Improve pH → when using buffered solutions

• Improve GFR → decreased uremic acids

• Decrease blood glucose → dilution and increased excretion

• Improve electrolytes
Electrolytes to think about
• Sodium

• Potassium

• Phosphorus
Electrolytes to think about
• Sodium
• Often low due to shifting with glucose Rule of thumb: pick fluid
• Also loss through urine with Na close to the serum
level
• Potassium Get overly concerned if Na
<125-120 mmol/L or > 170
mmol/L
• Phosphorus Then you only want to
adjust the sodium by 0.5
mmol/hr or 10-12
mmol/day
Electrolytes to think about
• Sodium

• Potassium
• Mildly elevated – cellular shifting with acidemia
• Low- due to decreased intake and loss from kidneys
• *** shifts intracellular with insulin***

• Phosphorus
Electrolytes to think about
• Sodium

• Potassium

• Phosphorus
• Varies
• **** Shifts intracellular with insulin
 K+ supplementation
Scott’s sliding scale → helpful in a hurry
but not as accurate as it doesn’t take fluid
rate into account

K concentration Potassium supplementation K concentration Rate of K+ potassium

(mmol/L) (mEq/ L) (mmol/L) supplementation
(mEq/kg/hr)
<2 80 <2 0.5
2-2.4 60 2-2.4 0.4
2.5-2.9 40 2.5-2.9 0.3
3-3.4 30 3-3.4 0.2
3.5-5 20 3.5-5 0.05-0.1
Don’t exceed 0.5 mEq/kg/hr
How much KCl if the serum K = 2.7?
Case info:
Body weight 5 kg
Fluid rate 40 ml/hr
• Rate of K+?
• 0.3 mEq/kg/hr (from looking at the chart on the left on previous
slide)

Note: this isn’t much

• 5 kg x 0.3 mEq/kg/hr = 1.5 mEq/hr different from Scott’s
sliding scale value but it is
on a fluid rate 3x
• 1.5 mEq/hr x hr/40 ml x 1000 ml/1L = 37.5 mEq/L maintenance. If this
animal was only on
maintenance, then they
would be getting a lot less
How much KCl if the serum K = 2.7 (if only on
Maintenance fluid rates)?

• Rate of K+? Case info:

• 0.3 mEq/kg/hr Body weight 5 kg
Fluid rate 10 ml/hr
• 5 kg x 0.3 mEq/kg/hr = 1.5 mEq/hr

• 1.5 mEq/hr x hr/10 ml x 1000 ml/1L = 150 mEq/L

Ideally don’t exceed 80 mEq/L KCl due to phlebitis

and pain
What if it isn’t improving?
• Do you need to supplement more?

• Hypomagnesemia
• Low magnesium decreases potassium retention at the level of the
kidney making normalizing potassium levels more difficult
Phosphorus
• Risk of hypophosphatemia
• Acute hemolytic anemia (< 0.5 mmol/L)

• Dose range: 0.02-0.12 mmol/kg/hr

TIP: Cheat way for K+/Phos for DKA with
normal lytes
1) Determine amount of K+ needed

2) If potassium and phos relatively normal or low normal at starting Insulin →

targeting 0.1-0.2 mEq/kg/hr K+
Using the higher end of K+ supplementation compared to a normal patient
because going to be adding insulin

3) Do ½ from KCl and ½ from Kphos

Example of cheat way
• Ex: Potassium: 3.5, Phos 0.8
• Decide to supplement potassium at 0.2 mEq/kg/hr
• If still 5 kg cat and 40 ml/hr: ~25 mEq/ L (0.2mEq/kg/hr x 5 kg x hr/40
ml x 1000ml/L)

• 12.5 mEq/L KCl

• 12.5 mEq/L K from Kphos

• Check Phos: 12.5 mEq/L Kphos x ml/4.4 mEq = 2.84 ml/L Kphos
• 2.84 ml/L x 3 mmol/ml = 8.5 mmol/L x 0.04 L/hr / 6kg = 0.06
mmol/kg/hr Phos
• How much Kphos and KCl (in ml) do you want to
add to a 100 ml burette?

BW: 5 kg
Phos supplementation: 0.06 mmol/kg/hr
Potassium supplementation:0.2 mEq/kg/hr
Fluid rate: 40 ml/hr
 Phosphorus and Potassium***

• Phosphorus
• 0.06 mmol/kg/hr x 5 kg =0.3 mmol/hr
• 0.3 mmol/hr x hr/40 ml x 100 ml/burrette = 0.75 mmol/100ml burette

• 0.75 mmol/100ml burette x ml/3 mmol = 0.25 ml Kphos

• 0.25 ml Kphos/100 ml burette x 4.4 mEq K/ml = 1.1 mEq K /100 ml
burette
Potassium and Phosphorous***
• Potassium
• 0.2 mEq/kg/hr x 5 kg = 1 mEq/hr
• 1 mEq/hr x hr/40 ml x 100 ml/burette = 2.5 mEq/100 ml burette
• 2.5 mEq/burette – 1.1 ml from Kphos = 1.4 mEq K needs to come from KCl
• 1.4 mEq K/100 ml burrette x ml/2 mEq K = 0.7 ml from KCl

• 1.1ml of Kphos and 0.7 ml from KCl

Know what about the insulin??
Discussions of Insulin therapy
• IM vs IV?

• Start early vs. start late?

• What type of insulin?

IM vs. IV protocols for insulin

IV IM
• Constant infusion • Don’t need as much equipment
• Don’t need to poke as often • Frequent injections
• Higher risk of an overdose

Disclaimer: there are many protocols out

• Need equipment there, but these are the ones that I have used
and have seen documented, but others are
• Insulin binds to plastic documented as well
IM vs. IV protocols

Blood glucose
IM protocol Dextrose supplementation IV protocol
(mmol/L)
>14 0.2 U/kg Humulin R IM None 10 ml/hr
11-14 0.1 U/kg Humulin R IM 2.5% dextrose at maintenance 7 ml/hr
rate
8-11 0.1 U/kg Humulin R IM 5% dextrose at maintenance 5 ml/hr
rate
5.5-8 No insulin 5% dextrose at maintenance 5 ml/hr
rate
<5.5 No insulin 5% dextrose at maintenance Stop insulin
rate
IM protocol
• Check blood glucose every 2-4 hours
• Give Humulin-R IM based on blood glucose check
• Add dextrose as needed
IM protocol - example

Time BG Plan
BG IM protocol Dextrose supp
8am 26 0.2 U/kg Humulin R
>14 0.2 U/kg Humulin R IM None
11-14 0.1 U/kg Humulin R IM 2.5% dextrose 10am 20 0.2 U/kg Humulin R

8-11 0.1 U/kg Humulin R IM 5% dextrose 12pm 15 0.2 U/kg Humulin R

2pm 7 No insulin- start dextrose

5.5-8 No insulin 5% dextrose
4pm 15 0.2 U/kg Humulin R
<5.5 No insulin 5% dextrose
6pm 12 0.1 U/kg Humulin R and
start dextrose
IV protocols
• Things to remember
• Only good for 24 hours
• Binds to plastic
• Dispose of first 50 ml through the line first
• Use new line every 24 hours
IV protocols- making the infusion
• Supplies • Add 2.2 U/kg of Humulin R to
• Humulin R insulin 250 ml bag (for dog or cat)
• 250 ml bag of saline • Historically added 1.1 U/kg for cats
but in my experience takes longer
• Fluid line to resolve DKA
• Label
• Run ~ 50 ml of fluid through the
line due to plastic binding

• If dextrose → this can go in the

other fluids going in
Side note: Dextrose supplementation
• Typically 2.5% or 5% added based on chart

• Adding 50% dextrose to your liter bag

• To get a 2.5% solution → add 50 ml of 50% dextrose to 1 L fluid bag

• To get 5% solution → add 100 ml of 50% dextrose to 1 L fluid bag

IV protocol

Dextrose Time BG Insulin CRI rate

BG IV protocol
supplementation
8am 26 10 ml/hr
>14 None 10 ml/hr
11-14 2.5% dextrose at 7 ml/hr 10am 20 10 ml/hr
maintenance rate
12pm 15 10 ml/hr
8-11 5% dextrose at 5 ml/hr
maintenance rate 2pm 7 5 ml/hr + 5% dextrose in fluids
5.5-8 5% dextrose at 5 ml/hr
maintenance rate 4pm 15 10 ml/hr
<5.5 5% dextrose at Stop insulin 6pm 12 7 ml/hr + 2.5% dextrose in fluids
maintenance rate
Important to remember
• Reason to check BG so frequently
• Push the insulin

• NOT to keep it normal

• Ideally stay in the 6-16 range but know there will be variation
Early vs. late insulin
• Rationale for late

• Brain produces idiogenic osmoles due to ↑ glucose

• Take time to metabolized

• If BG drops quickly → cerebral edema

• Early insulin → more rapid resolution of DKA
• No difference in hospitalization length or complications
Type of insulin?
• Typically, a short acting insulin → Humulin R

• Other types?
• 1-2 U/cat glargine q 12 hours SQ + 1-2 U IM at various intervals
• All cats → hypokalemic
• 12/15 cats hypophosphatemic → 2/12 hemolysis → transfusions
• All discharged within 5 days
• Client only needs to buy 1 bottle of insulin
• Their recommendation:
• 1-2 U/cat glargine SQ +
• 0.5-1 U/cat IM starting several hours post fluid resuscitation
• Continue every 4 hours as needed for glycemic control (1-3 doses average)
• 8 cats → low dose IV CRI regular insulin
• 8 cats → SQ glargine + IM regular insulin
• 0.25 U/kg glargine q 12 hours SQ + 1 U regular insulin IM q 6 hours if BG >14
• 11/16 cats survived (no difference between groups
• SQ/IM group → shorter time to resolution of bloodwork
• SQ/IM group → shorter duration of hospitalization

• No difference in time to eating

When to start long term insulin?

• Eating
• Resolving Ketonuria/ketonemia
Conclusions
• DKA considered in any diabetic who is ill

• Look for the underlying disease

• If not a previous diabetic, important for owner to understand long term

commitment

• Fluid therapy and electrolyte management = top priority

• Insulin is important for ultimate treatment and resolution of DKA

Fluid therapy
• Replace dehydration
• Come up with your % based on PE/Hx

• Ex 5 kg cat with 8% dehydration (poll)

• 5 kg x 0.08 = 0.4 L = 400 ml