Nightrider's in DKA

I knew something was very wrong. After learning Sunday his sugars were high, he had keytones and glucose in his urine, the emergency vet let me take him home after 12+ hours admitted. I was told to give him 1 unit BID and to follow up with a primary vet. We had an appointment today, but he was so sick, so I called to tell them and they said to go back to emergency. We decided to go to a different emergency vet since the last place didn't seem to do anything for him except charge me money.
The care of plan is to find out why his sugars are elevated (did not happen at first emergency vet) and to bring his sugars down. Lots of fluids and ultrasounds to look at his liver and pancreas. Poor little guy.

 

Sending lots of healing vines for Nightrider, fingers and paws crossed that he will be soon on the mend! Please keep us posted!

 

((((((Jen & Nightrider))))))

I'm very sorry to hear that Nightrider is in DKA. I was concerned when I read your other thread that the previous emergency vet might not have kept him in long enough to flush the ketones out of his system and stabilize him properly but I didn't want to say too much for fear I'd spook you; the diabetes diagnosis on its own is overwhelming enough. DKA really needs veterinary intervention and close management in a hospital setting. Very, very poor and completely inadequate response from that first emergency vet. The new emergency vet sounds much more with the programme, thank goodness.

Try to take heart from the knowledge that your boy is where he needs to be right now and getting the veterinary attention necessary to get him better. All the stress and worry does take a lot out of a body when our little ones are ill. While he's being looked after by the vets try to eat what you can and get as much rest as you can; it will stand to your credit when Nightrider comes home.

Sometimes DKA cats have a tough time eating after an episode so it'd be a good idea to talk to the vets about giving you an Rx for anti-nausea and appetite stimulant meds to take home so that you are ready to respond should Nightrider have any appetite problems when he gets home. Going forward it's very important to more closely monitor ketone-prone cats at home so that should they make a reappearance you can respond promptly proactively. Urine test strips are the most common way of monitoring ketones but you can also get ketone blood testing meters (similar to glucometers). The meter test strips are pricey but the advantage blood meters offer is that they can detect the presence of ketones possibly days sooner since it takes a while before ketones start to show up in a cat's urine.

If you search the forum for posts by member @Meya14, you'll be able to find a lot of extremely useful information about DKA.

Fingers and paws crossed in the Shire for Nightrider to feel much better very, very soon. Be sure to post if you need a bit of moral support in the meantime and please keep us updated with his progress.




Mogs
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Vet called. His pH was 7.08!!!! They did an ultrasound, his liver and pancreas are OK. He's started on insulin and fluid drips, they replaced his potassium and phosphate also. He'll get some nausea meds too.

I feel horrible about how sick he is. I'm a RN so I understand the pathophysiology on DKA, but I'm also his mama so my emotions are high.

I'll be getting things together so I can care for him at home. Glucometer & low carb foods.
Thanks for the healing love for our little guy!!

 

((((((Jen))))))

Thanks for the progress update, Jen. My heart goes out to you. My Saoirse has chronic pancreatitis and last year she started to go off her food not long after starting on insulin. I didn't know as much as I do now about how to help her (big thank you to members here for that) so I tried to find a food that would be easy for her to eat. One of the foods I gave her triggered a major flare (contained carrageenan). She got sooooo sick. Guilty doesn't even come close to describing how awful I felt.

I'm very glad to hear that his liver and pancreas are OK. With you being an RN and Nightrider's mama bean, I can appreciate how your medical knowledge can be both a boon and a bane at times like this.

I think the general view here is that when a kitty is recovering from DKA carbs are a secondary consideration; calories come first.Whatever the cat will eat is the right food for right now, and the insulin can be worked around it until a solid, stable recovery has been achieved.

I just had a quick look at a recent thread that Meya14 contributed to. Here's a link to one of her posts with a handy home care checklist which might be helpful for you.

http://www.felinediabetes.com/FDMB/...and-dont-know-what-to-do.149794/#post-1570518

If there's anything we can help with, just let us know. We're rooting for you both. I do hope you manage to get some rest. (Not easy in such a worrying situation.) When you visit Nightrider please give him some 'get well very soon' scritches from me.



Mogs
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Update:
Nightrider did ok overnight. His electrolytes are still low, but his keytones are down, so that's good news. He's getting antibiotics and milk thistle since his bilirubin's still above normal values. I ordered a glucometer from amazon (a fraction of the cost the vet quoted us), and we'll be donating his dry food to the neighborhood feral cats. He won't be home anytime soon, he needs to eat and drink well before he can come home. I keep focusing on him surrounded by light and comfort hoping our Rainbow Kitty "Klobah" (his best friend we lost in Sept) is with him and protecting him.

Thank you for being here, it's good to know we're not alone.

 

Sending some extra healing white light to Nightrider!! Come on boy...we're all pulling for you!!

 

Oh, Jen, I'm very sorry to hear about Klobah. That must be making things even tougher on you right now.

I'm very glad to read that Nightrider did OK overnight and that his treatment is improving things. More healing vibes on the way from the Shire ...


Mogs
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Glad your kitty is getting good care at the vet. DKA is a rough road, but many cats recover fully. If the vet reports abnormal liver or kidney values, these often time improve once the hydration and abnormal metabolism get back to normal. If a cat has a DKA episode, it's an indicator that they are more prone to these, especially when sick, dehydrated, or stressed. Learning to hometest for ketones will help you catch and treat them before they progress to DKA.

 

Sending Tons of Prayers and healing vines for Nightrider.

 

He came home 1/8. I'm checking glucose reading Q 12 hrs. He loves his fancy feast. Eating, drinking, purring!!

 

Glad to hear Nightrider is home!!!

What insulin are you using?

It's also important to get tests in more often than every 12 hours because what's most important in dosing is how LOW it takes them, so if you only test before each shot, you won't know how effective that dose is

We like to see tests before each shot (to make sure they're high enough for insulin at all) and then if at all possible, a midcycle test on the AM cycle and then a "before bed" test on the PM cycle.

If you can't get mid-cycles due to work every day, it's even more important to get tests on the evening cycle. Most cats go lower at night, so getting that "before bed" test at night can give you a heads up for when you might want to set an alarm to get up and get more tests later on (Welcome to the world of sleep deprivation!! )

We have a spreadsheet we really like to use that helps us to see the "patterns" that we look for in our kitties...it'd really help if you'd start keeping track of the test results you get so we can help you in the future!

Here are Instructions on getting the FDMB spreadsheet but let us know if you have any problems! We'll be happy to help!

 

Welcome home, Nightrider!!!!!!!!!!!!



Happy dance!
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Should I test before or after meals? Or both? I was thinking, let him eat, then test.

 

So glad to hear Nightrider is back home and feeling better.

 

Glad Nightrider's home and doing well! Always test first, then feed then shoot. That way your number is not food influenced.

 

He's 28 mg/DL. He doesn't seem like his sugar is low. Having food now, alert, going to recheck in an hour.

 

Hi Jen,

I see you're using an Alphatrak - 28 is far too low. You need to get his numbers back up.

You need to act NOW.

If Nightrider is on insulin can you retest him IMMEDIATELY and let me know what his BG is.

If it is still under 68mg/dL give Nightrider honey or Karo ASAP.


Mogs
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PS ... I am watching your thread for an update. You're not alone, OK!

1. Please can you confirm that Nightrider is on insulin.

2. Please can you confirm which insulin Nightrider is being given. What dose?

3. Please can you confirm how long after the insulin injection that you got the 28mg/dL reading (Alphatrak), e.g. if the injection was test was 3½ hours ago, that would be +3.25.

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After a finger tip of honey, 5 treats, some more food: BS 158!

 

Phew! I'm very relieved to hear from you and that Nightrider's back in safe numbers. (It's tough when you're miles away and waiting to hear back in these situations. )

That's the immediate emergency out of the way. Now you need to make sure he stays in good numbers.

Please can you answer the questions in my previous post about insulin and timings, Jan.

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Lantus
Last dose .5 units after BG of 312 (last night 6:30 pm) +14 hrs

 

No official spreadsheet, yet. But keeping track on paper.

 

Thank you.

To make sure I understand correctly, the last dose of Lantus was given last night and Nightrider has not had any insulin this morning. Is my understanding correct? Please confirm.


Also, how many days has Nightrider been on 0.5 IU Lantus?

If more than 3 days, was he on a higher dose before? If yes, what was the previous dose?
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The paper record will do fine for now, Jan.

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No insulin since last night. Day 2 of insulin at home.

 

Received 1 unit 1/8 after leaving the vet w/BS of 240. Then I gave .5 last night

 

Thanks. For the current situation it's good news that Nightrider did not get insulin this morning: it will allow the depot to drain a little.

I'm getting confused with the data. Sorry to be a pain but could you complete the following list for me so that both myself and others replying to this thread will have a better picture of Nightrider's doses. (Highlight the text with your mouse then copy and paste it into your next post and replace the ???? with your dose, BG and time data - leave the question marks if you don't have data for a particular item.)

---------------------------------------------------------------------------------------------------------
LANTUS INSULIN - BG READINGS ARE mg/dL ALPHATRAK VALUES!

1/8/2016:
AMPS = ???? - Dose = ????
AM Mid-cycle lowest BG reading = ????
PMPS = ???? - Dose = ????
PM Mid-cycle lowest BG reading = ????

1/9/2016:
AMPS = ???? - Dose = ????
AM Mid-cycle lowest BG reading = ????
PMPS = ???? - Dose = ????
PM Mid-cycle lowest BG reading = ????

Today:
AMPS = ???? - NO INSULIN GIVEN. (Previous dose 0.50 IU Lantus given 12 hours earlier.)
BG = 28 at +??? hours since last dose.

Fed 5 treats (carbs unknown) and a fingertip of honey at: +??? hours since last dose.

BG = 158 (after honey and 5 treats) at +??? hours since last dose.
--------------------------------------------------------------------------------------------------------------------------------


Did you give high carb treats or protein treats, Jan?

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Sorry for delay getting back to you there, Jen. Internet connection threw a wobbler.

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Glad you got Nightrider back in the good numbers! All that abbreviated data is confusing to me too. Guess it'll take a while to adapt. I am keeping a log but gotta learn and get with the abbreviations everyone uses on the forum. I've been noting actual times of testing and insulin. And now there's the memory on the meter, too.

 

IMPORTANT:

Jen, please can you test Nightrider's BG again ASAP please? The carbs from the honey don't tend to last very long.

If the BG is 70 or less give a little more honey and a teaspoon of gravy from a high carb food if you have some in your hypo kit. If not, give him another few treats (I am assuming they're high carb - please confirm).

If he's 80-100 feed him a teaspoon or two of his regular food (no more than this - you don't want to fill him up in case he needs more to get him through the rest of the cycle).

If he's > 100, no need to feed yet.


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Jen, please can you update us with what's happening? Getting fretty here.

 

Sorry. I'm a night shift ICU nurse. Nightrider and I were snuggling on the couch and had a nice nap. I will complete the information you asked for. We're going to do a sugar, too. I'll be back...

 

BS 331.

 

1/8/2016: AMPS = @ vet - Dose =1 unit @ 7am at vet
AM Mid-cycle lowest BG reading = 279 @ 2pm
PMPS = did not check, vet said to give - Dose = 1 unit
PM Mid-cycle lowest BG reading = no recheck, I went to work

1/9/2016:
AMPS = 35 - Dose = 0 wet and dry food, ate well
AM Mid-cycle lowest BG reading =no re check (I see that I need to check more)
PMPS = 312 - Dose = .5 unit
PM Mid-cycle lowest BG reading = no recheck
Today:
AMPS = 28- NO INSULIN GIVEN. (Previous dose 0.50 IU Lantus given 12 hours earlier.)
BG = 28 at +14 hours since last dose.

Fed 5 treats (carbs unknown) and a fingertip of honey at: +14.5 hours since last dose.

BG = 158 (after honey and 5 treats) at +15 hours since last dose.
BG= 331 @ 1400

 

treats are high carb, Temptations brand.

 

Yep you are right, Temptations, Meow Mix treats are all high carb. Check out the ingredients...it is a very long list. Here is some low carb treat information.

Treats: It is always nice to have treats available for your kitty especially when testing or when they decide not to eat. I like using Pure Bites. I have found it at Petsmart and other pet stores. It is freeze dried and the only ingredient is the meat i.e. chicken, duck, etc. If your cat likes it, then I would go to the dog section where it is cheaper than the cat package. It is bigger package and bigger chunks but no problem in breaking it up. Another option is to use Bonita Flakes where you can find at your local Asian market. There is a link here somewhere in this site that has a list of low carb treats.

 

I am so relieved to hear from you, Jen. I was very worried when things went quiet. I am glad that all's OK with you both.

Thank you for filling in the dosing and BG history. It is something for members here to refer to for now.

First up, because of that VERY LOW number today, the amount of Lantus Nightrider is receiving needs to be adjusted. This is really tricky because of his recent DKA episode. It is critical that he always has enough insulin in his system because you don't want to trigger a DKA relapse. It is also tricky because Nightrider may be more sensitive to insulin after today's low.

I recommend in the strongest terms that you seek advice now about what to do about insulin dosing BEFORE the next dose is due. If you post on the Lantus & Levemir support group's board asking for dosing advice in your thread title, you should get some suggestions on dosing to discuss with your vet. You need to let the L&L members that Nightrider is recovering from DKA and has had a biochemical hypo today. The easiest way to do that - and to let them see the insulin and BG data you have posted - is to link to this thread. I've put the link to the start of this thread below. If you copy it to the clipboard and then paste it into your opening post on the L&L board, members will be able to read 'the story so far'.

Link to start of this thread:

http://www.felinediabetes.com/FDMB/threads/nightriders-in-dka.150475/

NB: Be sure to highlight to them that you use an Alphatrak meter.

Nightrider is in high numbers now, but that may be due to the effect of the Temptations treats and he may possibly bounce of that low of 28mg/dL. The L&L people will be able to help you with all of that. Also ask them for information on managing low numbers for the future. (Sometimes numbers drop back even after the high carbs, so it's safer to keep testing for a little while after a low.)

Very relieved you're both OK; 28 is W-A-A-A-A-Y low on a human meter. On an Alphatrak it's crazy low. Heaven forfend, but should you ever find Nightrider below 68 and on your Alphatrak and asymptomatic, if he's very low give some honey and high carb then post immediately onto the L&L board with a title along the lines of "HYPO ALERT - +4 - 57 ALPHATRAK" and set the thread title prefix to 911. If you don't get a quick response there, do the same on Feline Health. (They're the boards with the greatest footfall.) You should then get support steering Nightrider back to safety from experienced members. If Nightrider is low and you even suspect the slightest hypo symptoms then give honey or karo and take him to the vets (particularly if it is less than 12 hours since his last dose).



Mogs

(BTW, I have the utmost admiration and respect for your vocational calling. )

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Until he is fully recovered from the DKA, at least 2 weeks no ketones and normal eating patterns, you want to skew on the higher side with the blood sugars. >100 but less than renal threshold or ~250. This will give you a buffer so that you can give every dose of insulin and not skip which may cause the DKA to back slide. I've seen with insulin-sensitive cats that have been in DKA, often times the ketones are related to an ongoing calorie deficit. If you are feeding very low carb food, you may consider adding some additional carbs to provide more substrate for the insulin to act on so your cat isn't burning fat reserves to maintain blood sugar. Once he is fully recovered, you can reduce the carbs and reduce insulin to account for blood sugars.

Also, how much and what food is your cat currently eating each day. Foods vary in the amount of calories they provide, and sometimes we accidentally underfeed when switching foods. A typical weight and activity cat should have between 200 and 300 calories a day when diabetic. Calorie counts are sometimes listed on the food label.

 

Hi Jen,

Just checking in to see how you and Nightrider are doing today. It would be great to hear from you.


Mogs
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An afterword ...

I hope I didn't overwhelm you earlier, Jen. It was an emergency situation and there was very little data to work with.

I hope you'll be able to set up a spreadsheet for Nightrider.

 

We're doing great!! My husband has taken BGs on his own! I had help with my SS, I just need to become more familure with it. Nightrider is eating, we bought Wellness "Core" dry food that was low carbs (10%) I believe, and likes fancy feast (does not like the turkey giblets flavor). Nightrider lost a lot of mass during the DKA. He's doing normal Nightrider stuff, not quite the same guy, but better than last week!!! I've been reading all the links and taking notes. Still need keytone sticks and urine strips. I was very overwhelmed the other day, but we appriciate all the info, just can be difficult when it comes in so fast. No low number for >24 hrs. I'm at work now, so I don't have them on me. One BG at a time...

 

we're mixing the low carb dry with the dry he was on before DM. It's taste of the wild mixed with Blue Wilderness (gluten free, high protein) which he loves

 

What a great update! It's excellent news that Nightrider's appetite is so good.

It's great that you've got your spreadsheet now. You'll get into the run of it very soon, and as the data builds up it will help you a lot going forward.


Mogs
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