Hello all - a long complicated story, but the general gist of my question is how best to get his BG numbers down without doing more damage to the rest of him. We know he is basically on hospice but we want to keep him as comfortable and happy as possible. the long version - on Tuesday 7/21, Niki ate breakfast and went to the regular vet for a cat bite that had become infected. Wound was cleaned out and nothing remarkable was noted. Wednesday 7/22 he was out of it. Rushed to ER. Low bp, high K, low temp, unreadable BG. He was considered critical with sepsis. On IVs, etc. He developed pancreatitis, high liver values, kidney issues, high WBC. His BG was high enough that they were giving him Lantus plus fast acting insulin (Humelin?). He has an ng tube because he wasn’t interested in eating. He is on RC Renal Support liquid food. They put a Libre on him but it is reading -80 less than regular testing. We brought him home today. He has been tolerant and mostly mobile throughout his stay and was happy to be home. His kidney values have dropped a bunch, which was one of their worries. His WBC had increased significantly overnight, so they changed antibiotics. The main issue/question that we have is the insulin and food timing. They want us giving him the RC food 4-6 times per day (30ml each time through his ng tube). But his BG was reading HI on both the Libre and the Relion. How do we balance the timing of the food and his high BG readings? Increase the dose? Vet would not give us the Humelin (understandable) so we are stuck with the Semglee. He was interested in some of his regular food when he got home (great!) but he will still need the ng tube until he eats on his own regularly. I’m sorry for such a long complicated story and thank you for reading this far. If he had not shown a decent amount of improvement on a number of levels over the past few days, we may have made a different choice. We realize that the overall prognosis is not super positive but we think that he is best served and happier here. nancy
Hi Nancy. Poor Niki, he has been through a lot. I am glad to hear he is eating bits of food on his own. That is positive. I would stick with one or the other meters on the SS and reporting here, otherwise there will be confusion. It is fine to test with the other but keep it separate.. Are you able to get the lab reports from the vet and post them on the SS? That would be helpful. As far as the feeding goes. I would give the ng feeds as directed but keep them 2 hours away from the preshot BGs so they are not food influenced at this point. And let him eat what he wants inbetween except for the 2 hours preshot. Stay with the insulin dose you are giving until the numbers tell you otherwise. Post daily for help and guidance. Are you testing for ketones in the urine? If not I would daily at the moment. why don’t they think he will get better?
Thank you so much for the reply. I’m just so emotionally whipped and stressed that I don’t know which way is up anymore. I will put just the Relion numbers on his SS from now on. I have over 50 pages of his records from the vet. I can sit down and put them all in the SS tomorrow. As the vets told me, they would try to keep his insulin shots every 12 hours, but it really seemed that their testing was all over the place as far as timing. The meals were a little more consistent, but it looks like they were doing 2 bigger feedings a day, then went to more, then back to 2. They did say that they did their best to balance everything, but things got pushed around due to the high volume of emergencies that they see every day. The medical notes, although readable, are difficult to make sense of relative to the timing of what they were doing for insulin and food. we will do as you suggested for the food and the pre-shots. That was basically what we had been doing since we adopted him but this whole situation has really thrown us for a loop as far as the feeding and shots! they tested every day for ketones, but we definitely will have to keep doing that, thanks. I believe that they don’t think that he will get better because he has had so much going on at once. They are worried about his WBC count and inflammation, as well as his bite wound, which is necrotic and may need surgery at some point in the future if everything else can be resolved. They won’t put in an EN tube because his BG is so high. it was just reading HI” again at +4 right now, sigh. I know Hi is better than low, but some movement downward would be encouraging. thank you so much for your help!
I can imagine how stressed you must be. I am sure he is happy to be home again though. When are they retesting the WCC to see if the new antibiotic is working? Did they take swabs of the wound to see which antibiotic the infection responded to? im going to ask @Marje and Gracie if she can have a look at the lab results for you. If you could even add the ones that are listed in the lab column of the SS that would be a good start. I know how busy you must be though. If he has an infection that will be keeping his BG higher. That’s is also why it is important to check daily for ketones.
Hmm, they said to recheck his numbers in 2 weeks. But I can certainly get our regular vet to check it sooner if recommended. We seems to live there anyways, lol. I do not think they took swabs of the wound. This is his second broad spectrum antibiotic (the vet did change it after they did not see a response right away). But we do not think that they did a culture. The WBC swings were pretty dramatic though. I will try to get the results in the SS tonight - I appreciate all the help! thank you!
I would not wait 2 weeks to get a repeat WCC, especially if you don’t see an improvement in him. What antibiotic do they have him on?
I have been putting all of the lab work (or what I think is the lab work) on the SS. All of the timing for the BG readings is way off - and it seems there are 2 separate sheets with overlapping numbers per day, so I am going to have to write it all out and get it in tomorrow. i can’t keep my eyes open - I’ll be back tomorrow! thank you so much!
Yes I would bring him to the reg vet within a week of starting the new antibiotics so see if they started working. Don't wait two. His bg will go down when the infection clears.... Right now that and eating are the main concern.
Just looked at the labs. Did they send him home with sub q fluids? He looks like he could use them to help flush those kidneys and get the bun down. Also what are they doing to address the anemia?? That is getting concerning. At the very least start him on b vitamins (b 12 methylcobalamin and a b complex) to support that. The anemia can cause weakness and lots of appetite. I don't see any numbers for the wbc.?
they didn’t even want to send us home with subq! We asked about it and then they okayed it. So he is supposed to get 100ml 2x/day which seems like a lot for a 7 lb-ish cat. (Our CKD cats follow the 10 ml per pound per day guideline). But we don’t know how much IV fluid he was getting at the ER. I’ve been through all the records several times and I don’t see any WBC numbers! All I know was (my written notes) 7/22 26000 7/23 29000 7/24 22000 7/25 34000 I did ask about B12 yesterday and did not get an answer. I have a call in already this morning to ask them these questions. Plus every BG reading last night was HI and the two this morning have been also. thank you!
That is way too much fluids for a 7 pound cat. My 16 pound boy got 100ml. and occasionally 150 for very brief periods a few times. Do check with your regular vet. I hope the antibiotics kick in. The kidney values could very well come down a lot when the infection is gone.
RC Renal Support liquid food: COMPOSITION: milk and milk derivatives , cereals, oils and fats, vegetable protein extracts, minerals, derivatives of vegetable origin. Source of protein: milk low lactose, caseinate, soya protein concentrate. Additives (per kg): Vitamin A: 3330 IU, Vitamin D3: 320 IU, E1 (Iron): 30 mg, E2 (Iodine): 0.3 mg, E4 (Copper): 1.8 mg, E5 (Manganese): 2.4 mg, E6 (Zinc): 28 mg, E8 (Selenium): 0.15 mg. Additives (per kg): Vitamin A: 3330 IU, Vitamin D3: 320 IU, E1 (Iron): 30 mg, E2 (Iodine): 0.3 mg, E4 (Copper): 1.8 mg, E5 (Manganese): 2.4 mg, E6 (Zinc): 28 mg, E8 (Selenium): 0.15 mg. Detailled Composition (for Wetonly): Milk low lactose, maltodextrin, vegetable oil (including oil rich in arachidonic acid), calcium caseinate, potassium caseinate, soya protein concentrate, minerals, fish oil, mono&diglyceride of fatty acids, marigold extract (source of lutein)- Additives (per L): Nutritional additives: Vitamin A: 3330 IU, Vitamin D3: 320 IU, E1 (Iron): 30 mg, E2 (Iodine): 0.3 mg, E4 (Copper): 1.8 mg, E5 (Manganese): 2.4 mg, E6 (Zinc): 28 mg, E8 (Selenium): 0.15 mg.
I agree with Elise @tiffmaxee that does seem like a lot of fluids to give 2x a day Tyler's brother was getting 100 ml once a day , he had kidney disease I would check with your regular vet like Elise suggested
so is this bad at this point? I think that they said that they were doing this to help with his pancreatitis and to help with getting rid of the beginnings of hepatatic lipidosis. thanks for the help!
Oh good I am glad he's getting fluids. I think a week or so of 100 is probably ok as long as there are no heart issues. If he's cooperative you could always do it 50 am and 50 pm. Once he's well hydrated I'd back that down to 70 ml per day.
Well Renal foods are very high in carbs so that's a factor in the high numbers. You might need a little extra insulin to compansate in the meantime. Once his kidneys stabilize and he's eating you can switch to a low carb/low phosphorus food like weruva.
thank you. That makes perfect sense - I had no idea that it was that high carb. All of our CKD cats are on Weruva foods from Andrew Hall’s list (or other foods off his lists because they hate Weruva periodically). I know he has a list for the low carb/low phosphorus foods!
Hi there. I just love you for everything that you're doing to Niki! So far, for the labs that you've put in, I can see that you have substantial improvements in Niki's condition. I am really concerned about you giving 100mL of sub-q fluids twice a day! That is way too much for a 7 lb. cat. WAY TOO MUCH. Some vets seem to think that you cannot overhydrate a cat. It's crazy. I have personal experience a small cat being given too much sub-q fluid and then got pleural effusion. It did not end well. Remember, you cannot equate IV fluids that ago into the bloodstream with subcutaneous fluids. They are not processed in the same way by the body. I would re-check that with my vet and even if they told me to give that much, I would not. Those white count numbers that you mentioned are scary. Very high. In my opinion they should be coming at this with more than one antibiotic. That is not at all unusual for vets to do. Have they said that the bite would is the primary source of the infection or do they think that there is another source in the body (kidneys? somewhere else?) They definitely should be working on trying to identify the specific microbe(s) involved, but the two antibiotic approach is probably good to do in the interim. As for the hematocrit, it's not that bad yet. It's not good, and is something to keep an eye on, but it's not yet dropped low enough to start treatment with ESAs (erythropoetin stimulating agents) that are done via injection and will stimulate the bone marrow to produce more red cells. Sorry if you are already familiar with this information. This may just be what they call the anemia of chronic disease where the body is struggling because of the disease process -- in this case an infection which has clearly challenged the kidneys, which produce the erythropoetin that stimulates the bone marrow to produce those red cells -- so I guess I'm saying that as his kidney values (hopefully) improve... so will the anemia. I have found that different vets have their own threshold of when they will start ESAs (Epogen, Darbepoetin). Did the labs say that the anemia was "non-regenerative?" I definitely would not wait two weeks to re-check at least the CBC. One week would be good.
Oh my I just saw you were giving the 100 ml TWICE a day. I thought it was once a day. Yeah that's way too much. I thought that was once a day. I wouldn't do 200 ml a day for a 7 lb cat. Does he still seem dehydrated? Are his gums wet or sticky? Does his scruff go back quickly when you pull it?
More thoughts... I am really happy to see the improved phosphorus levels! That's fantastic. Same with bilirubin! Wow, that his potassium at the very beginning was so scary. Very dangerous. They dealt with that pretty quickly, I see. The ALT is still high. If you can start your Niki on a supplement called Denamarin soon, that would be fantastic (you can ask your vet about it, many of them sell it although it's cheaper from Chewy.com... but I'm not sure where you live so I don't know if you have access to Chewy.) You probably can't start yet until you can pill your kitty. Since it's an NG tube and not an E tube, I don't think you can crust pills up and put them in there can you? How are you getting the antibiotic in there (are they liquid?) Milk thistle is also very healing for the liver, but the Denamarin is a double whammy with two key ingredients to heal the liver. Did they do an abdominal ultrasound? Did they check Niki's heart at all (via ultrasound?) (I'm just thinking of those fluids again).
And finally... (hopefully for you) ... about ketones. I would recommend getting a blood ketone meter. This will show ketones in the blood before they show up in urine. ADW Diabetes Supply sells the one I have used (NovaMax Plus ketone meter... also tests BG, but I never used it for that.) The strips are expensive. About $1.80 each, but much cheaper than a DKA. ADW gives you a free meter if you buy the ketone strips. My kitty went DKA so after this I was obsessive about testing him for ketones. He had high ketones for quite a while afterwards, but when his BGs started to come down his ketones came down as well. He also had hepatic lipidosis dx via ultrasound.
Yes. I'm so glad to see that you know about Andrew Hall's lists! He also is really a nice person and answers questions posted to him on FB (even though I'm sure people ask him the same stuff over and over). I used the renal foods in my cat (Weruva BFF Play before we switched to renal foods) and they are high carb, but it didn't seem to affect his BG strangely... but ECID and I think he was a special case in that way (acromegaly probably with a working pancreas). The only way to tell if they spike him very high is to feed different foods and test. But aren't you stuck right now with the liquid diet going through the NG tube?
thank you! I have a call in to my vet about the subq numbers. I agree that they are way too high and hope that they give me a much more reasonable number for Niki. I will also ask about a second antibiotic. I got the impression that they are too busy of an ER to do a ton of investigation. Hopefully my vet could do it or send us somewhere else that could do it. Like so many areas of the country, it’s difficult to be seen unless it is an emergency. I’ll tell them that I really don’t want it to become another emergency as he has been through enough already! They said the infection was most likely from the cat bite, but indicated with diabetics it might be something else of unknown origin. He had mild pancreatitis about a month ago, but I don’t know if that would be a factor. They did mention that the anemia was consistent with hemodilution. They did not indicate if it was non-regenerative or not. Our regular vet’s threshold I think is 15 (off the top of my head, I may be wrong). We were able to do EPO shots for another of our CKD cats (it worked well for a few days but he had a total crash and didn’t make it). When I talked to the ER this morning, they did say that we could do a B-12 shot as well as daily B complex vitamins if we wanted. So he will get that later. He was hungry for real food (Fancy Feast) as I was writing this so he had a bit more (it is actually his regular small snack time) so that was good. Getting rid of the ng tube is a goal. I will also make an appointment for a recheck on his values next Monday (vet closed Fri-Sun). thanks so much!
You've got this! I am impressed. You are obviously experienced with CKD. That's half the battle. I am really excited that he's eating! Can you pill him? I really recommend the Denamarin. It helped my Darcy's liver enzymes get back down after his hepatic lipidosis. And, of course, just eating and drinking normally again is half the battle. I think Niki is on the way!! Yes, all those IV fluids will affect the HCT readings (as well as lots of other blood tests as you know, I'm sure). I'm sorry about your other kitty who had CKD and didn't make it. Did they give you meds for nausea? Are you still using them (if you did)? Cerenia? Ondansetron? Maybe if Niki is hungry you won't need them now? I just know that Cerenia is helpful in pancreatitis (not so much for nausea, but for the anti-inflammatory properties that it has for the pancreas -- lots of people with panc. cats use it daily... although I'm not sure of the dose for that purpose. I always did B-12 shots (cyanocobalamin) and oral B Complex and methylcobalamin
We are supposed to feed him 4-6 times/day through the ng tube with the RC. But they also want us to try to offer him real food first (which they had done at the ER but he pretty much didn’t want it). If he eats on his own, we are to reduce the amount we give him through the tube. We are just supposed to make sure he is eating the correct amount of calories to at least maintain his current weight (lost 2 lbs in the ER), as well as a hedge against further pancreatitis as well as hepatatic lipidosis. Until we can get this stuff under control, I won’t be messing with new foods. (geez I sound like I know what I am talking about, lol) We rely heavily on Andrew Hall’s lists in this house! I’m always muttering to myself in Petco and the feed store looking at the lists. Especially when each CKD cat does not like the same thing! thank you,
He He does not seem dehydrated although I keep checking (he is getting irritated because I’m hovering)! thank you!
Thank you. CKD is such a bear. Thank you for your kindness. We have the four with it now (not counting Niki). We have lost 4 others with it in the last two years. We always do what we can but sometimes it is not enough. yes, we can pill him. He’s a pretty good sport (although apparently he was getting testy at the ER yesterday). When we adopted him, he actually had one elevated liver value so our vet did put him on Denamarin. No matter what we did, he would start vomiting, sometime hours later. So we took him off that. Although his value came down, it was always at the high end of normal. I will ask if there is an alternative though. We gave milk thistle to one of our liver disease dogs, but I don’t know if that’s an option for cats. Yes, he is getting cerenia in a pill as well as transdermal mirtazapine. Hopefully he will keep eating and not need as many meds! thank you!
Yes, the antibiotic is a liquid. The Cerenia is in pill form but we have been able to give that to him. They did not do any ultrasounds. But they were very cognizant of possible heart issues because of his very low bp and pulse, as well as the sepsis. Either way, he is definitely going to get fewer fluids (he got 75ml this morning so he might not get any tonight). We had one vet who told us that there was no way that we would be able to keep him alive with just subq. That by taking him off the IV fluids would just cause his kidney values to skyrocket and that would be it. So maybe that’s what they were trying to do by telling us to do so much fluid? I don’t know. We have a blood ketone reader (don’t remember the brand) and have had no luck with it. In the past it has told us that he had ketones, so we would rush him to the vet and he would be normal. So it looks like we will be buying the one you recommended, as getting a urine sample is almost impossible. thank you!
hahaha yes they don't like the hovering. he's afraid you are going to bring him back to the vet. omg my ckd cat allie has a vet appointment today. she is SO HARD to get into the box, and the poor thing pees herself every time. I would not give more than 100 ml in 24 hours.
thank you! I swear they know if we even think they are going to the V-e-t (even if we spell it). We have one that will not pee on herself, but will make sure she pees on us. Always. And then there is the 15+ pound evil one, who has gone psycho several times and put my husband in urgent care twice with multiple cat bites. We can’t even get near him to give him calming pills. Sheesh. thank you!
You know, I went through the same thing with my cat. My ketone meter would give me a significant reading and I would take him to the vet and they would test his urine and say it was negative. I was really ticked off that they wouldn't take it seriously (especially after everything we had been through). I did a bunch of research on the reliability of blood ketone meters and was convinced that they are quite accurate. I totally did not trust their urine dip stick tests. They did not trust my meter. One day they brought out the dipstick to show me the color. I may have some of those papers saved on my other computer still - that discuss the reliability of blood ketone meters and what/how they measure. They do not measure the same thing as the urine sticks. I basically got to the point where I would just tell them that he wasn't feeling well and to please put him on IV fluids for the day, and they did it. I probably couldn't have gotten away with this at any other vet, but they know me because I am such a Frequent Flyer Quadruple Diamond/Platinum Member! Fortunately this group helped me get his BG down so that ketones started to come down.
Yes. You can give plain milk thistle to cats. We have several people that I know of right now @Summer and Susie for example, who are giving it to their cats right now. Summer? Her cat, Susie's, liver enzymes have improved.
Yikes, what a traumatic time you're having. I can only weigh in on the ketone meter - 2nd vote for the Novamax (also doubles as a BG meter using different strips). I rely on it now for checking ketones - for Minnie it definitely shows the rise much earlier than urine tests. I start taking action on her ketones based on blood readings while the urine is still showing negative. Minnie has a tendency to get ketones and with her last DKA the vet had us supplement the Levemir with Regular insulin as her ketones rose. So, good info for you to have and report to the vet if Niki's ketones rise. Good luck. Good news with the appetite! And hope you get some sleep too, definitely helps.
Yes, I am blown away by how much lower my Susie's ALT test and AST test are now. She had been very high with both of these test for several months. I started giving her the milk thistle about 4 months ago. I'm supposed to be putting it in her food twice a day but I only do it at night. Her high levels have dropped dramatically. I can't think of anything else that would have made a difference for her.
Hi Liz. So it's probably wrong of me to have thought that anytime Shooter's bg's are high his ketones are high and vice versa? Also, is it strange that Shooter drinks a lot of water when his bg's high AND when they are low? I thought they would be less hungry and thirsty when staying in lower ranges (although right now he's not staying low at all).
Just a FYI … vet said no more than 100 ml subq fluids a day max for Niki. and of course his PMPS was 274, so I am questioning if 1.5 units is the correct dose for tonight (I started another thread so that I don’t get more confused). you all rock!
I'm not sure of the answer to that, all I know for certain is that when BG is high you should definitely be on the lookout for high ketones. There are other things which can influence the ketones - this sticky has a lot of good info. Ketones, Ketoacidosis, and Diabetic Cats: A Primer on Ketones Minnie's appetite is high when she has high BG and also when she has very low BG (lucky for me when she hits the limes) but typically she only drinks a lot when BG is high (300s+) - though having said that, she drank some today with a BG in the 200s, which was unusual for her.
