Any experience with aftercare for DKA?

Discussion in 'Feline Health - (The Main Forum)' started by Dashesofrainbow, Mar 13, 2019.

  1. Dashesofrainbow

    Dashesofrainbow New Member

    Joined:
    Jul 24, 2016
    Hello all! My sweet kitty, Milo, just came home from a 6 day hospital stay for the dreaded ketoacidosis. It was an absolute rollercoaster that I wouldn't wish on anyone. Many days we thought he'd never make it home, but he finally did this afternoon. We are absolutely thrilled but Milo is terribly lethargic and drinking a lot of water. I know he must be exhausted but the water drinking is concerning. Does anyone have any experience with a kitty surviving DKA? If so, what did you experience when your cat came home? I'll call the vet in the morning when they open but I'd like to hear from some people that have experienced this, as well. Thank you in advance!
     
  2. Chris & China (GA)

    Chris & China (GA) Well-Known Member

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    May 10, 2013
    Sorry to hear Milo was so sick!! DKA is so hard on them!!

    It's pretty common for them to continue to act sick for up to several weeks afterwards but what's important now is to make sure you get as much food into him as possible, the right amount of insulin and check for ketones often (at least once a day)

    If you don't already have them, get some urine ketone strips so you can keep track of him at home (or there are blood ketone meters you can buy that catch the production of ketones earlier)

    There are quite a few members who've been through a DKA and came out the other side so hopefully you'll hear more from them soon.

    As for the water, the more water you can get into him the better right now to help flush out any remaining ketones and to help flush out any more that might develop.
     
  3. Bron and Sheba

    Bron and Sheba Well-Known Member

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    Feb 21, 2015
    Hi, welcome to you and Milo. You have come to the right place for lots of help, information and support.
    I am sorry Milo has had DKA. It is a horrible illness and there is a lot you can do to help in his recovery.
    I'd like to ask a few question first so we can find out about Milo.
    What insulin is Milo on and what dose?
    What are you feeding him?
    How is his appetite?
    Did the vet send you home with any anti nausea tablets?
    Did Milo have an infection or inflammation as well and did they treat it with antibiotics?

    The recipe for DKA is not enough insulin, not enough food and an infection /or inflammation such as pancreatitis.
    So what you need to do now that he is at home is to make sure Milo is getting enough insulin, enough food and the infection /inflammation is being treated.
    It will all seem overwhelming at first but we will help you every step of the way.

    One of the best things you can do is go out and buy a human glucose meter from Walmart, or a pharmacy and start testing the blood sugar levels (BSLs). It sounds daunting but it is not and it won't hurt Milo. I will put a link at the bottom of this post for you to see how it is done. If you are testing the BSLs you can see if it is safe to give the insulin and you can see how low the dose is taking Milo. After DKA it is extremely important that Milo is getting enough insulin and the only way to tell is to be testing the BSLs..
    Your vet may say it is not necessary but I can promise you it is very important for Milos recovery.
    While you are at Walmart or the pharmacy you will need to buy a bottle of Ketostix and test Milos urine for ketones. It is a simple tst and not hard. Keeping ketones out of the picture is very important.
    So when you go to the pharmacy or Walmart buy:
    One Human glucose meter
    One box lancets size 28
    Some cotton balls to hold behind the ear to test and to hold over the prick afterwards.
    One bottle Ketostix

    We recommmend you test before EVERYinsulin shot to see it is safe to go ahead with the shot and then test again about 4 to 6 hours later depending on the type of insulin given to see how low the insulin is taking Milo.

    What food are you feeding?. We recommend feeding wet or canned low carb food....10% or less. We don't recommmend dry food at all. It is too high carb for diabetic cats.
    However at the moment the most important thing is that Milo IS EATING. So if he won't eat the low carb food, feed him whatever he will eat.
    Hopefully the vet has sent you home with some anti nausea tablets such as cerenia and ondansetron. After DKA cats often have a poor appetite and often need these anti nausea tablets to stop the nausea so they will feel like eating. If a cat is nauseated he won't eat and we know how very important it is to eat. You can feed Milo often throughout the day. Depending on the type of insulin, feeding times can change a bit.. for example if you have a faster acting insulin such as vetsulin you need to make sure Milo eats well before his dose but if it is a long acting insulin such as Lantus he doesn't have to eat it all before the shot but can have some a bit later.

    If you have time can you get up your signature which is at the top right of this page under your user name. Click on it and choose signature. Tell us yours and Milos name, dateof diagnosis, the DKA, type and dose of insulin, type of food, anyother illnesses and meds. Then click save. We read this every time we help someone and it saves having to ask the same questions every time.

    Here are some links
    For home testing
    http://www.felinediabetes.com/FDMB/threads/hometesting-links-and-tips.287/

    For setting up the spreadsheet to put in all the BSL....it is a great sheet and helps us a lot to help you.
    http://www.felinediabetes.com/FDMB/threads/understanding-the-spreadsheet-grid.156606/

    I am going to tag @Kris & Teasel To help with the dosing and finer points of managing post DKA.

    All lots of questions, it is a steep learning curve in the beginning but we are very happy to help in any way that helps get Milo better and back to his old self.:):bighug:
    Bron
     
    Last edited: Mar 14, 2019
  4. Kris & Teasel

    Kris & Teasel Well-Known Member

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    Aug 17, 2016
    I've been through DKA twice with Teasel. I wouldn't wish it on anyone ...

    Here are the basics of recovery treatment at home:
    • kitty needs calories - up to 50% more than normal - to prevent ketone formation from metabolic breakdown of body fat and muscle (you might have to syringe feed)
    • during recovery wet food should be high enough in carbs to support a large enough insulin dose to prevent ketone formation - maybe mid range carbs (10 - 15%?)
    • insulin in a large enough dose and do not skip a dose - ask for help in deciding on a lower dose if PS us lower
    • hydration is very important - add extra water to all wet food meals and/or give subQ fluids in amounts appropriate for the kitty (be careful if there are cardiac issues - ask the vet)
    • use meds as needed: 1. antinausea/vomiting (Cerenia or ondansetron); 2. appetite stimulant (mirtazapine or cyproheptadine) if anti nausea meds alone aren't enough; 3. diarrhea meds if that's an issue (metronidazole or tylosin)
    Know that recovery can be slow and it could be weeks before your kitty is back to normal.
     
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  5. Dashesofrainbow

    Dashesofrainbow New Member

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    Jul 24, 2016
    Wow, this is a lot of information! Thank you!
    What insulin is Milo on and what dose?
    He is on Prozinc, 1 unit 2x a day which will probably go up after I bring him to the vet in a few days.
    What are you feeding him?
    Friskies. Only pate with 5% or below in carbs. I used this forum frequently when he was first diagnosed and chose what you guys were recommending.
    How is his appetite?
    His appetite is decent but for all the wrong things. The vet gave him dry food and that's all he's willing to eat.
    Did the vet send you home with any anti nausea tablets
    Yes, they gave him Cerenia.
    Did Milo have an infection or inflammation as well and did they treat it with antibiotics?
    It was not stated if he did for sure but he's on Clavamox 2x a day

    I hope I did my signature correctly! I will get the strips, unfortunately I cannot miss any more work after all the days I missed when he was sick. So I can't test for another 12 hours. Hopefully that won't be an issue! Thank you again!
     
    Last edited: Mar 14, 2019
  6. Dashesofrainbow

    Dashesofrainbow New Member

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    Jul 24, 2016
    I'm sorry that your Teasel had to go through this, too. What I'm unsure of is the emergency vet won't let me increase his insulin for a few days. It's 470 before eating and he's only eating dry food right now. She told me it's important because if he has pancreatitis, he will become sensitive to insulin again and he may get too high a dose. Should I call my normal vet for a second opinion? (I denied the ultrasound to determine exactly why this happened as it was thought that he wouldn't make it anyway)
     
  7. Dashesofrainbow

    Dashesofrainbow New Member

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    Jul 24, 2016
    Thank you. You made me feel better about the water. The vet does not suggest keeping an eye on ketones at this point. She said it's bound to have some ketones left because his blood sugar is still high. Should I call my normal vet for a second opinion? I appreciate all the help here. I'm on my phone this morning so I can respond in greater detail when I get to my computer.
     
  8. Bron and Sheba

    Bron and Sheba Well-Known Member

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    Feb 21, 2015
    Thanks for the information and getting the signature set up. It sounds like you are testing the BSL already. That is great. Can you tell us what type of meter please and pop that onto the signature as well. Thanks.

    I am glad @Kris & Teasel has replied. She is very experienced with DKA and has helped many kitties with the recovery here.
    I disagree with the ER vet. It is really important to keep testing for ketones so please get the Ketostix and test at least daily st this point.
    I would certainly tell your normal vet what has happened. A second opinion won’t Hurt.
    Try and get some inbetween tests in when you are home. Are you leaving food out for Milo when you are not there?
    Keep asking questions.
    Bron
     
  9. Dashesofrainbow

    Dashesofrainbow New Member

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    Jul 24, 2016
    Sure thing! I have the AlphaTrak meter. I will get the ketostix, but how should I go about testing? I read on this forum to try pieces of plastic bag in the box to collect some urine?
    I am leaving food out, but it doesn't look like he ate any today. I am going to try to get some high calorie food to see if that works for him.
     
  10. Dashesofrainbow

    Dashesofrainbow New Member

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    Jul 24, 2016
    @Kris & Teasel Do you have any advice on syringe feeding? He's not eating well today, and while his BSL is 370, I want him to eat before I continue insulin. I don't think he's actually swallowing his Entyce (appetite stimulant); he seems to drool a lot after, and I think it may actually be him pushing the Entyce out of his mouth.
     
  11. Bron and Sheba

    Bron and Sheba Well-Known Member

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    Feb 21, 2015
    If Milo will let you, put a small container or large spoon under him when he goes to the litter box. Otherwise you can crumple some plastic and hope it catches some urine. Or if he has a favourite spot to pee, put a small container there.
    Did you give some cerenia or ondansetron before the appetite stimulant? If Milo is nauseated he won’t feel like eating and an appetite stimulant is not good to give if the cat is nauseated.
    Try any food at this point. He needs to eat.
     
  12. Bron and Sheba

    Bron and Sheba Well-Known Member

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  13. Dashesofrainbow

    Dashesofrainbow New Member

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    Jul 24, 2016
    Do not skip a dose even if he has not eaten a meal? I'm sorry for so many questions. I was unfortunately unable to be the one that picked Milo up from the vet so I didn't have the chance to ask the vet all of this. She did tell me to call her with any questions, but I don't think of them until I see these comments.
     
  14. Bron and Sheba

    Bron and Sheba Well-Known Member

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    Feb 21, 2015
    Don’t ever be sorry for asking questions.
    How long before the next dose of insulin is due.?
    How long since he has had either cerenia or ondansetron?
     
  15. Dashesofrainbow

    Dashesofrainbow New Member

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    Jul 24, 2016
    I will see what I can work out with the spoon. I can maybe slide a lid of sorts under him while he's peeing.
    Look at you and your genius! That's a good thought. This morning, I gave him the appetite stimulant right after the nausea medicine. This evening, I slipped him a little more of the Entyce as I feel he spit it out. I am giving him his antibiotic last so the nausea medicine can kick in. Should I give the nausea medicine well before the appetite stimulant?
    Thank you for the video on assisted feeding. I will check it out.
     
  16. Dashesofrainbow

    Dashesofrainbow New Member

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    Jul 24, 2016
    I just gave it to him just in case he was sneaking food throughout the day. His blood sugar is 370 so I figured it wouldn't hurt. I also syringe fed him a little canned food just in case but he got pretty mad about it so I stopped.
    He got cerenia 12 hours ago.
     
  17. Bron and Sheba

    Bron and Sheba Well-Known Member

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    Feb 21, 2015
    How often is the cerenia prescribed?
    If you could also get some ondansetron from the vet, that can be given every 8 hours if necessary and works on a different centre in the brain and it can be given at the same time as cerenia.
    If necessary you might need to go back to the vet and get another cerenia injection for Milo to get him over the hump until he feels a bit better.
    I would give the cerenia an hour to work before the appetite stimulant I think.
    it is really important Milo eats, as I am sure you know, and he gets his insulin.
    Keep asking questions.
     
  18. Bron and Sheba

    Bron and Sheba Well-Known Member

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    Feb 21, 2015
    Cerenia is given once daily, don't give it more often. If Milo is still not eating ask the vet for some ondansetron. it may help.
    What do you mean "in case he was sneaking food throughout the day?
    With assist feeding....try little bits often if Milo will allow at this stage. Hopefully Kris will come along soon. I am not experienced with assist feeding.
    Maybe add to your subject line "help with assist feeding" don't take the DKA out of the subject line though.
     
  19. Dashesofrainbow

    Dashesofrainbow New Member

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    Jul 24, 2016
    It is prescribed once every 24 hours (1/2 pill). I will give it to him before the stimulant from now on, thank you.
    They did give me some gabapentin for future vet visits. I can try to give some to him now though. It's just a larger pill and apparently, Pill Pockets for cats are impossible to find. I'm going to get some from the vet in the morning, but I will see if I can get him to take one.
    I will call the vet in the morning. I just don't want to put him through another vet visit if I can help it at all. It's presumed that the stress it caused is the reason this happened. He went in on Tuesday of last week and got his blood work done and treated for an ear infection. His blood work and urine were perfect. On Thursday, he entered ketoacidosis.
    I syringe fed him some broth from one of those packets you can buy for cats. He took a decent amount of that though I'm unsure of how many calories that actually has.
     
  20. Bron and Sheba

    Bron and Sheba Well-Known Member

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    Feb 21, 2015
    You are a good mama bean. Keep trying to get something into him.
    Maybe the vet will give you an injection of cerenia to give at home.
    Did you get some of the recovery wet food that Kris suggested from the vet?. that would be a good idea.
     
  21. Dashesofrainbow

    Dashesofrainbow New Member

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    Jul 24, 2016
    Thank you, I'm certainly trying and it breaks my heart that he isn't feeling well.
    I will certainly ask about getting some Cerenia to give at home!
    I had some of the Recovery from in between hospitalizations but he is not interested in wet food. I'm going to get more from his primary in the morning with the pill pockets as it's easier to get through the syringe than Friskies.
    I did give him his ondansetron which he held in his mouth until I went to check if he swallowed. It was partially dissolved but I popped it back in and never saw it again. I hope that helps him feel better. He seems to be falling asleep in his water bowl. The vet told me it's completely normal for him to drink a lot of water as his blood sugar is still not regulated, but he's getting himself soaked in it. I'm not even sure if he's really drinking or just laying his face in it.
     
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  22. Dashesofrainbow

    Dashesofrainbow New Member

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    Jul 24, 2016
    Oops, didn't see this comment. Sorry. I won't give him more of the Cerenia. I did give him a smidge more of the Entyce as he isn't taking it all in.
    He's had dry food out and there's another cat here that seems to be keeping an eye on him. He may have saved some of his breakfast for Milo, but I was at work all day so I wouldn't have noticed some kibble missing.
    I watched the video you sent and it helped a lot! The 1 ml at a time was what finally got him. He fought a lot less when I slowly eased the food into his mouth. I guess I was thinking of a baby when I was feeding him before and just continuously squeezed lightly.

    *I forgot I can edit posts, so adding this to the comment: "I feel that I should note I do not normally let him have kibble or free feed. I am only doing it to make sure he eats. He gets 1 can a day/2x a day when he isn't sick." I will ask his primary about Purina DM or another DM kibble while he's getting better.
     
    Last edited: Mar 14, 2019
  23. Dashesofrainbow

    Dashesofrainbow New Member

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    I feel that I should note I do not normally let him have kibble or free feed. I am only doing it to make sure he eats. He gets 1 can a day/2x a day when he isn't sick.
     
  24. Bron and Sheba

    Bron and Sheba Well-Known Member

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    Feb 21, 2015
    No reason why he shouldn't free feed.
    I have to rush out and collect kids from school. will be back later:)
     
  25. Dashesofrainbow

    Dashesofrainbow New Member

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    Jul 24, 2016
    I just realized I was confusing ondanestron with gabapentin because my mother used to take both! I have gabapentin for anxiety, but I will ask about the ondansetron. I guess he'll be napping for a little bit because of the gabapentin.
    I feel pretty terrible about the mix-up. I hope it helps him get some sleep at least. He's been pacing a lot of the day from what my father said.


    Edit - I rubbed his favorite treat on his lips (do cats have lips?) to try to encourage him to eat and he made a gagging motion. Do you think it's likely that he is just nauseous?
    One more note: I gave him insulin 3 hours ago after I found blood sugar to be at 370. I checked it again since he hasn't eaten, and it is now 400? This is after his medicine, but should it have gone up? I understand not changing due to insulin resistance but goodness. The emergency vet suggested a curve on Saturday to see if we need to increase his insulin but I don't want him to relapse before we get a chance.
     
    Last edited: Mar 14, 2019
  26. Bron and Sheba

    Bron and Sheba Well-Known Member

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    Feb 21, 2015
    It does look as if he is nauseated.
    Have you got a spreadsheet up and running yet?. It is really hard to give any advice about dosing if you don't have a SS. So I think if you can get it up and filled in with any BSLs you have already taken., that would make things much clearer for us. If you have any trouble getting it set up, post and ask for help.
    When you gave the insulin 3 hours ago when the BSL was 370....was that at the normal time that it was due?
    Has Milo eaten any food since the last insulin dose?
    @Kris & Teasel lives in Canada so it is probably the middle of the night for her. Hopefully she will be online in the morning to help you with dosing.
     
  27. Dashesofrainbow

    Dashesofrainbow New Member

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    Jul 24, 2016
    I've only taken his blood sugar three times since he's been home, but I started the spreadsheet. It looks right so I hope I did it okay.
    Yes, that was the normal time it was due. I syringe fed him some 'broth' from a pack of Fancy Feasts after the insulin as he hadn't eaten that I know of and didn't want to give him his antibiotic on a completely empty stomach. I noticed the Cerenia says for dogs only - does it sound right that he was prescribed this? I looked it up online and it just seems to not be FDA approved for cats in tablet form but also that the injection causes pain. I wonder if that's from the medicine or the syringe.
     
  28. Kris & Teasel

    Kris & Teasel Well-Known Member

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    Aug 17, 2016
    I'm glad you have your spreadsheet up! It'll help us to help you. In a nutshell:
    • syringe feeding is a stop gap - it's hard to get enough calories in this way which is why:
    • antinausea meds need to be given first - Cerenia (4 mg or 6 mg) is given once a day with ondansetron added if Cerenia alone isn't enough, or ondansetron instead of Cerenia
    • give an appetite stimulant only if the antinausea meds have been allowed to kick in and don't seem to be working (maybe a few hours later?)
    • Cerenia is routinely used in cats even though the package might say for dogs
    • the antibiotic might be contributing to inappetance. Is there a verified infection?
    • continued testing of urine ketones is essential - minimum once a day for now
    • sometimes a feeding tube has to be put in to get the kitty through the anorexic phase - not as scary to deal with as you might think
    • the couple of BGs on your spreadsheet are high and need to come down but until you get more test numbers it's hard to say how much insulin he needs.
    Here's the basic testing routine we recommend:
    1. test every day AM and PM before feeding and injecting (no food at least 2 hours before) to see if the planned dose is safe
    2. test at least once near mid cycle or at bedtime daily to see how low the BG goes
    3. do extra tests on days off to fill in the response picture
    4. if indicated by consistently high numbers on your spreadsheet, increase the dose by no more than 0.25 u at a time so you don't accidentally go right past a good dose
    5. post here for advice whenever you're confused or unsure of what to do.
    This is useful: http://www.felinediabetes.com/FDMB/threads/hometesting-links-and-tips.287/

    While your kitty was in hospital for DKA he should have been given fast acting insulin to get BGs down and fluids with electrolytes. Potassium levels in particular can get messed up. Did your vet discuss what treatment was carried out with you?
     
    Last edited: Mar 15, 2019
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  29. Kris & Teasel

    Kris & Teasel Well-Known Member

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    Aug 17, 2016
    It's the Cerenia itself that stings.
     
  30. Dashesofrainbow

    Dashesofrainbow New Member

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    Jul 24, 2016
    I only have a phone available to me now so I will fully respond around 8:30 Eastern time. They did make sure his electrolytes were good before he went home. He stayed there three days longer than expected because his phosphorus was low.
    My primary vet and emergency vet are working together to decide the best course of action. I'm doing a curve tomorrow and they're leaving towards Mirtazapine for nausea.
    The infection was not confirmed, no. He did have an ear infection before bringing him in and they had him on corticosteroids. I stopped that when he got sick so I'm not concerned about the antibiotic. He always gets that last anyway. Anything I did not respond to will be responded to when I'm home. I apologise. Thank you for your help!
     
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