Explaining Diabetic Ketoacidosis (DKA)
In this episode, Dr. Sugerman discusses Diabetic Ketoacidosis (DKA) in pets and shares a real-life case of a dog named Ranger. He explains the role of insulin in managing blood glucose levels, the significance of ketone bodies, and the process of diagnosing and treating DKA. Dr. Sugerman also discusses the prognosis and aftercare for pets with DKA. Tune in for an informative and educational episode on DKA in pets.
What You’ll Learn:
What diabetic ketoacidosis (DKA) is and how it affects the body
A real life case seen by Dr. Sugerman and understand his thought processes during the diagnosing phase
How we treat DKA patients and the importance of hospitalization
Potential prognosis for DKA patients and what their post-hospitalization future may hold
Ideas Worth Sharing:
"All cells need glucose in order to work." - Dr. Tyler Sugerman
"Just watching them to see what they're doing will really help to determine whether they're vomiting, regurgitating, or if they're retching like coughing." - Dr. Tyler Sugerman
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Read The Transcript:
Dr. Sugerman: [00:00:00] Alright, so we're going to talk about a story real quick. I had this dog that came into my work a few weeks ago. His name was Ranger, and he was an 8 year old miniature schnauzer. So he looked terrible. He was so dehydrated, I would have thought that he hadn't drank for like weeks at this point. His mom said, though, that he had been drinking tons of water lately, and then the last couple days when he drinks, he would just vomit it all back up.
So it's intriguing for me if you know me and know, like a good portion of my job and what I love to do is putting clues together. I love mysteries and I love puzzles. And so this whole process for me when I work, it's just a large puzzle for every patient. So I got to put all these things together, trying to figure out what's going on with that pet.
We're going to talk today a little bit about what I did to try to put those clues together to try to figure out what's going on with Ranger. So stay tuned as we unravel this mystery known as DKA.
Hi, and welcome to Vetsplanation. I'm your veterinary host, Dr. Sugerman, and I'm [00:01:00] going to teach you about veterinary medicine. In this podcast, we can dive deeper into the understanding of what our pets are going through and break down medical terms into easier to understand chunks of information. Just a quick disclaimer, this podcast is for informational purposes only.
This is not meant to be a diagnosis for your pet. If you have questions about diagnostics or treatment options, please talk to your veterinarian about those things. Remember, we are all practicing veterinary medicine and medicine is not an exact science. Your veterinarian may have different treatment options and different opinions.
The information I provide here is to help pet parents have a better understanding about their pets. If you like our podcast, please consider sharing this podcast with at least one friend or just somebody else who has pets as well. Now, let's jump into this week's episode.
Alright, welcome back my friends. If you have not done so, I would suggest listening to Dr. Z discuss diabetes prior to this lesson. I'll be giving you a brief overview before talking about [00:02:00] DKA, but she goes really in depth on diabetes and I think it's a, it's a great overview of it. So let's start talking about just like what DKA is. Stands for diabetic ketoacidosis.
Alright, don't run yet. I know that's really big words, but as usual, we're going to break all this down, right? So obviously, diabetes is in the name, diabetic. So let's start with a quick overview of diabetes. So an animal that is diabetic means that they have an insulin deficiency. They just don't have enough insulin.
Now, blood glucose is essentially the same thing as saying blood sugar. So when a person or an animal's blood sugar or blood glucose rises, The body will naturally release something called insulin. Insulin is extremely important because it helps blood sugar or blood glucose get into the cell.
When you think of insulin you can think of it as like a lock and a key situation. So insulin would be the key to help glucose get into a cell. So if glucose doesn't have the key, [00:03:00] then it's not going to be able to get into that cell in order to work. So all cells need glucose in order to work like literally every cell.
So you have to have this perfect pair of both glucose being in the bloodstream and insulin being ready to let it into the blood cells in order for it to work. You can eat a ton of sugar or a ton of glucose and not be able to use it if you don't have insulin.
Without insulin, that blood sugar or glucose just floats around in the bloodstream with really nothing to do. So eventually the glucose overwhelms the kidneys and spills into the urine. So in dogs and a good majority of cats with diabetes, we do need to give them an injection of insulin because that's what their body needs because it has stopped making insulin.
So we give the insulin and that allows the glucose to go back into the cells where it's actually needed now there's like I said much more in depth conversation with Dr. Z and some interesting things to learn about with cats who have diabetes. So I do suggest [00:04:00] listening to that. Alright, so let's talk a little bit more about DKA now that we have this overview like I said stands for diabetic ketoacidosis.
So now we know what diabetes is. So now we know the first part of this is that the pet does not have enough insulin that's being produced. So let's now break down ketoacidosis. So we'll start with the first part, keto, so this sounds like the dog is on a keto diet, right? That's not quite what it is.
So a keto diet was actually named after the process of ketosis. And that's where fat in the body is broken down or converted to something called a ketone body. Ketone bodies can be used by the cells sometimes when they're like desperately craving glucose but can't get it. Because there's no insulin to be able to help pull that into the cell. So normally, glucose or blood sugar is what the cells need to use to produce energy. So instead, in diabetic patients, they may use these ketone bodies as energy instead. So remember that insulin is [00:05:00] the key that glucose needs to be able to get into the cell, right?
What if I was talking about like a prison cell instead of a regular cell in your body, right? Insulin would be that key that the prison guard has that fits really nicely into the cell. You can let a very specific prisoner out. Everything's very orderly. You come out with, with the results that you want.
So ketone bodies are more like a rogue prisoner in a cell that started a riot. So they make the key out of soap to get in. They let their buddies out. They start smashing things. So in more medical terms, ketones are not a clean energy source. When ketone bodies are used instead of glucose, it creates this imbalance in our electrolytes and it makes our blood turn acidic.
Or a more technical jargon, acidosis, which means acidic blood. So when you think about like basic and acidic. Our blood would be more acidic. That's not good. We want it to be very neutral. We want it to be in the middle. We don't want [00:06:00] it to be acidic. So this turns into a huge disaster in the blood , and it leads to the patient becoming very ill.
Okay, so we learned about how the cells act normally with glucose and insulin, how diabetics cannot make adequate amounts of insulin, and how the body uses other bad forms of energy called ketone bodies for energy. But that leads to havoc in our bloodstream called Ketoacidosis. Not terrible, right? We were able to break that down into what DKA is called.
We just call it DKA because it's really annoying to say that long word all the time. Diabetic Ketoacidosis. We're just gonna call it DKA from now on. So like I said, these patients are really sick. When it gets to this point, they feel terrible. They're very lethargic. They're depressed, meaning they just don't really want to move around.
They are dehydrated. They're vomiting. Not eating and very nauseous, just like my friend Ranger who came in the other day. So based on the pet parent's signs she saw at home that Ranger was [00:07:00] drinking lots of water. For me, that already starts making me think of things that are going to make them drink a lot of water and diabetes is definitely high on that list.
There are definitely other diseases as well. When we start testing for things, that is definitely one of the things I'm going to test for. And then based on the fact that she saw that he was vomiting a lot, I put that together with him being an older guy and also his breed of a miniature schnauzer, which we'll talk about later.
And now DKA actually becomes the first thing on my mind that I'm concerned about. So we put all of these pieces together, even from just my physical exam. And what the pet parents saw at home. And now we've come up with, this is my, my first big concern. So any dog can have DKA, but Miniature Schnauzers are unfortunately a common breed to have this, along with another portion of this disease which we'll talk about later.
He had never been diagnosed with diabetes before. And I would say I see about half of these patients [00:08:00] already diagnosed with diabetes, and about half of them not diagnosed with diabetes by the time I have seen them. When I've seen them, some of them are going to be newly diagnosed , and some of them have already been on insulin at this point.
Even those on insulin can still go into DKA, and that usually occurs because of something that's causing some sort of inflammation or infection that's pushing them to use those ketone bodies because all of their glucose is being used for that infection and not in the cells where it needs it.
Or it's being overly used by the cells because it needs more of it. If there is no infection or inflammation, or at least it's caught early, then many diabetic patients do not go into DKA. The most common things that will cause some sort of inflammation or infection In the diabetic dog are pancreatitis, a urinary tract infection, and Cushing's disease.
Dr. Z talked about Cushing's disease in another episode as well, so definitely check that out. [00:09:00] In cats, the most common things are going to be hepatic lipidosis. I will definitely cover that on another podcast. It's definitely a big one. Pancreatitis, which I've talked about in the past, and something called cholangiohepatitis, which again, I will talk about in another episode.
All , so let's talk about like how DKA is diagnosed next blood work is usually the best way to diagnose diabetes, DKA, and the majority of the underlying causes. So in diabetes, we're looking for an elevated blood glucose, so elevated blood sugar, and usually that glucose is also in the urine as well.
Remember I said it's so overwhelmed in the body that it goes into the kidneys, which then spills out into the urine. So now we're going to be looking for that ketoacidosis part. If we look and see that the blood sugar is very high, the blood glucose is very high, then now we're going to look to see whether the pet is in ketoacidosis, we have something that tests for ketones in the blood, and there's a test for the [00:10:00] urine as well. Technically, the 1 in the blood is going to be the most accurate because everything has to be filtered through the blood 1st before I could even go to the urine. So you're going to see it in that blood 1st.
Next, we're going to be looking at what's called the blood gases. Basically, it just tells me, like, how acidic that patient's blood is. Those three tests right there tell me if that pet is in DKA, diabetic ketoacidosis. Next we look for the underlying cause. So we check the urine for a urinary tract infection.
This is very common because there's a lot of glucose or that sugar in the bladder and bacteria love sugar. So they will glom onto it wherever it is. We look at the blood work for a value called the lipase to see if that patient has pancreatitis, which I've again talked about another episode, and then we can look at the patient's liver values to to have an idea as to whether they might have Cushing's disease or not again. Dr. Z does a [00:11:00] great episode on Cushing's disease so I really suggest you go listen to that one if your pet also has Cushing's because I think that she really explains that very well.
We can't do the confirmatory test at that point because unfortunately they have to be not ill to do that. So we're going to be looking for all those other things and Cushing's is not something a quick fix is going to happen in the hospital anyways. We're also looking for things like hepatic lipidosis in cats, and then cholangiohepatitis in cats as well.
Like I said, I'll do another episode about those a little later on. Sometimes radiographs, or x rays is the other common term for them, or an ultrasound are going to be necessary to do things like checking for things like cancer or Some other underlying cause of what might be causing this inflammation or infection that push them into DKa. Because the pet already had diabetes prior to DKA now we have to fix the problem that caused the inflammation or infection in the 1st place. And we now have to manage the diabetes. So most [00:12:00] diabetic patients, when they're first diagnosed, do not need to be hospitalized it's not until they're in DKA.
They unfortunately have to be hospitalized. That is pretty much the only option before we talk about why and what happens in the hospital. I do usually discuss with pet parents at this point unfortunately, hospitalizing is not a guarantee that your pet is going to make it out of the hospital and they need to know that this is going to be something that they're going to require lifelong insulin injections for.
Not everybody can make sure that their pet receives those insulin injections twice a day or can commit to that for the rest of their lives. Therefore, I don't want to put the pet through a hospitalization if the pet parent can't maintain that lifestyle of getting this medication twice daily for the rest of their lives at home.
If a pet parent can't afford hospitalization or they're unable to give the insulin twice a day for the rest of that pet's life. Then we do talk about humane euthanasia at that point. It is not a wrong decision because, I don't want [00:13:00] the pet to go home and suffer. And they just can't get through this serious condition without being hospitalized, unfortunately.
Luckily rangers pet parents were able to hospitalize and he was a very nice dog. So they knew that injections of insulin were not going to be a problem. So now we have to talk about why we have to hospitalize and what to expect. So these patients are extremely dehydrated, like I said, and their electrolytes mainly potassium are out of balance.
Potassium is extremely important. It is inside the cells of the body and the rest is just stored in the bloodstream. Insulin is, again, an important molecule to tell potassium as well as glucose to go into the cells. So it's that key for potassium, just like it is that key for glucose. Now, if I try to send a patient home on insulin and just with some fluid under the skin, the pet parent would give the insulin, which would then make the blood sugar come down.
Potassium would plummet. And because it [00:14:00] goes into the cells, this makes the pet's blood more acidic, and unfortunately it becomes sicker. And it's also really extremely important for cells like the heart. If the heart doesn't have enough potassium, eventually the heart will stop. So when they're hospitalized, we're monitoring all of these things extremely carefully.
The first thing we do when we hospitalize is not something you'd probably expect. We do not give insulin first. We actually start them on IV fluids. That the reason for this is that we need the patient to be rehydrated when they are rehydrated that will bring the glucose down naturally and then not fully but but at least a little bit and I'll also help correct the blood being too acidic and will help get rid of a lot of those ketones as well.
Therefore, insulin is not the most important thing for us at this point. We have so many other things that we have to correct first to give that pet the best chance. They also get medication to help stop vomiting, which is called an anti emetic. [00:15:00] And if they have a urinary tract infection, then we're also giving things like antibiotics at this point to clear those things up.
If there's no urinary tract infection or no signs of infection, then they're not usually going to get an antibiotic. So other things that you might see, when you're visiting with your pet is going to be that they might have something like a feeding tube in. So that's really important because it helps us give them adequate nutrition.
We want them to get as much nutrients and keep their body getting as much energy and. And all those minerals and electrolytes and stuff as much as possible. They also might have something called a central line in, which looks like an IV catheter, but it's something that we draw blood from and a lot of times that is placed in one of the veins in the neck.
So I always tell people to be prepared when they see all these tubes, they have a tube that's coming out of their nose, which we feed them through. It goes from their nose to their stomach. We have this tube that's coming out of their neck so we can draw blood and not have to poke them over and over again because that's the most humane thing for them.
The nutrition part is also [00:16:00] extremely important for cats because it will help to either help with the liver problem, or it will help prevent a liver problem from starting. They can very easily get this hepatic lipidosis and cholangiohepatitis very quickly. And so we want to make sure that they get. the proper nutrition while they're in the hospital.
So now, rehydrating can take some time. It might be eight hours. It might be 24 hours. It might be 48 hours. It just really depends on, how fast we can give the fluids and how dehydrated they were in the first place. So we have to do that first before we can even start the insulin. Once they're hydrated though, then we're going to help bring their blood glucose down even more by starting them on insulin. We want to bring it down to a manageable level. It's probably not going to be completely normal, but at least manageable. So this could be in the form of giving them fluids that has insulin in it that's just constantly given to them.
That's called a CRI or continuous rate infusion, meaning we're just constantly giving them that [00:17:00] insulin and adjusting it as needed for what happens with their blood glucose. Or it might be that they're given injections. Which are pretty frequent and short acting types of insulin. So that way, again, we can adjust based on that pet's needs where their blood glucose is at that time.
So this again it will take time for them to get their blood sugar down and something that is going to be controllable. So once we've done that, the next big step is that we need them to eat. Once they eat, that's when we can start giving them the longer acting insulin, which is the same one that you'll be giving at home.
When they are in the hospital, like I said, we're monitoring their hydration, their potassium, their glucose, their blood acidity, their ketones, their phosphorus, all of this is managed very closely and adjusted constantly. So these guys are very critical until we get to the point where they are eating and on longer lasting insulin.
Therefore, when they're diagnosed at a regular veterinarian. They will likely need to be transferred to a 24 hour [00:18:00] hospital for around the clock care. This is the equivalent of thinking of them as needing to be in an ICU. They're usually hospitalized for about 5 to 6 days. I've had some that left the hospital at 3 days, and I've had some that left the hospital at 9 days, but I'd say the, the good majority of them are about five to six days, so it's not a quick treatment. It's not going to be like a drop them off, pick them up in the morning type thing. This is definitely going to be that they're hospitalized for a while. So once the pet is stable on their injectable, long lasting insulin though, they can return home at that point.
We show you how to give the insulin and if you've never done it before, talk to you about how you store the insulin, how to give it. Again, you can listen more to Dr. Z's. Podcast on our diabetes for more detail about those things. But here's a short rundown. So for cats, Glargine is great because it can actually help them potentially go into remission.
For dogs, either Vetsalin or NPH are the most common ones that are used. There are other ones as well. These are just the most common ones. [00:19:00] And the tricky part to this is that there are two different types of syringes. One is called a U40 and one is called a U100. It's not just a normal syringe, they have to be very specific insulin syringes for each specific type of insulin that you have.
The big thing at that is that there are two different concentrations, so it's really important that you get the correct syringes for that correct type of insulin. So Vetsalin and Prozinc, those usually use U40s.
And then Glargine and NPH usually use U 100s. There is another one called Detemir that's, I think, more common ish. That's a U100 as well, just in case you are using that. They get their insulin usually twice a day. It's really important that you make sure that they have eaten before giving that insulin.
For just talking about what kind of food that they should be on again, definitely go listen to Dr. Z's podcast on on diabetes with us, because she talks about great food sources for [00:20:00] them as well, if they don't have enough blood glucose, because they haven't eaten, they will make their blood glucose decrease dangerously low if they've been given insulin and no food to bring up that blood glucose.
So if I have my blood glucose kind of low, and then I give the insulin, it's going to drop it even lower. And really, we're not going to have enough blood glucose in our body. So we've got to make sure that they do eat prior to giving them those insulin injections. A few weeks later, the regular vet who will be monitoring the pet for kind of the rest of their life the long term of this is likely going to talk about what further testing to do to make sure that that pet's dose is right.
We put them on an initial amount, and then we have to adjust it from there as the cycle of their diabetes goes on. But I said, again, Dr. Z does a great job of talking about the follow up and all of that stuff on the interview I did with her. So I highly recommend you listen to the diabetes one as well, just to make sure that you understand what to do for [00:21:00] all the aftercare. So let's talk about our prognosis now. Like I said, this is, this is unfortunately a life threatening condition, which is why they do require extensive round the clock care. If they're not hospitalized, the chances of survival are about 25%.
And even with extensive care at home, that's, that's just not good odds. With hospitalization, about 75 percent of them will leave the hospital. Again, that's not a hundred percent. We can do literally everything we could possibly do in the hospital. And unfortunately they won't all make it. Now, there are some dogs who have not gotten to that point of having acidosis yet.
There's just what we call diabetic ketosis or DK. Those dogs actually have a pretty good prognosis because a lot of times they're eating pretty quickly. So if their blood is not acidotic, they don't feel as sick. So some of those patients actually have a better prognosis and will leave the hospital a lot faster.
All right, now a couple [00:22:00] of odd things that can happen. So some cats can, who have diabetes and are on a medication called Bexacat. If they are sick, their blood glucose will not be high because of the medication. Therefore we have to look for ketones in their bloodstream. Their, their system looks a little bit weirder like their blood work looks not quite normal because their blood sugar will be normal but their ketones will be elevated and their blood will probably be acidic as well. So we do have to know if that cat is on Bexacat that's gonna be really important to tell the veterinarian who's like looking into the blood work.
So Ranger had a weird twist to his disease as well. Again, like I said, I love puzzles, so it's all putting these things together. Miniature Schnauzers are the poster child for this disorder called hyperlipidosis. Hyper means that there's more or above, above normal. Lipids mean fat and the osis means just in the blood.
It's where basically there's just too much [00:23:00] fat circulating in the bloodstream. You probably know this better as like cholesterol or triglycerides. Those are essentially fats that are, that are around in the bloodstream. So now pets can have this and it's not a problem, but it can sometimes often lead to pancreatitis.
Sometimes there's no issues with it. Sometimes it leads to things like pancreatitis, which again, I've talked about in another episode so you can definitely listen to that, but it's basically just an inflammation of the pancreas. It can be a consequence of another disease, such as diabetes, or hypothyroidism, or Cushing's disease, but it can also occur from just like getting too many fatty table scraps, too much fatty food.
The most common dogs to get this are Miniature Schnauzers, like I said, but also Beagles, Shelties, Rough Collies, and Poodles can commonly get this as well. This complicates diabetes and DKA a lot though, there's no quick fix for this and it is [00:24:00] mostly changing the diet to a low fat diet and having weight loss that helps to fix that.
So it's going to take time, but the patient's DKA, right? Which means that they unfortunately have a worse prognosis when they're in the hospital and they've gotten DKA. Because of this Ranger unfortunately did not make it. His parents were obviously heartbroken, and we were as well.
But they did have another miniature schnauzer, Ranger's brother at home, and so they were able to help get him on the right track. They stopped giving him table scraps, they got him on a down to a healthy weight cause they were giving him love with food. but we talked about how we need to not do that especially just with his specific breed and they wanted to do everything they can to try to help avoid hyperlipidosis so that way he didn't have the same outcome as his brother so unfortunately you know for a ranger he didn't make it but his brother is doing fantastic you also might be wondering about things that can [00:25:00] cause people to bring down their lipids as well as if you go to the doctor, a lot of times we'll talk about some things that you can do to bring your lipids down like certain supplements.
Niacin is one of them. Unfortunately, they do have a tendency to cause cataracts and have a lot of other side effects in dogs. So they're just not as safe in dogs as they are with us. One safe thing that you can use to help bring down lipids is fish oil. So it won't do it quickly but it will try to help bring them back down to normal.
And again, cutting out all the fatty foods so that way the Are less likely to get this. All right. So I know there was probably a lot hopefully you have a better understanding of DKA, but we're gonna talk about our fun animal fact for today. So today we're gonna talk about the Foosa. It's also called a Fua or a Foosh
it's this weird creature. It's only found in the forest of Madagascar, and it looks like what you would get if you put together like a cat. A weasel, a dog, [00:26:00] and a monkey all together. It reminds me of, if anybody's played Whatchamadrawit, I will play as a family sometimes, and I this is what I picture is one of the things that says, it's draw an animal that is part cat, part weasel, part dog, and part monkey, and then you just get a Fossa.
So it has retractable claws like a cat has a long tail like a monkey, and it's tail is so long it's like half the length of its whole body. It has really round ears and short legs just like a weasel, and it has the face of a dog. I know that all sounds real weird, right? So like a wildcat, it can navigate in the trees of the forest with ease, just like jumping from branch to branch. Super cool. When it's on the ground, it's more like a flat footed bear, the way that it runs on the ground. It's really interesting.
All right, even with all their weird features, they are actually most closely related to the mongoose. Interestingly enough, they are carnivores, and they're at the top of the food chain of Madagascar. [00:27:00] They'll eat almost any animal, but they prefer to outmaneuver The swifty lemurs interesting like you can pick all of these different animals, but they want to they want to pick like the swiftiest of them, right?
So there are solitary animals except for the females with their young, their young are born with their eyes closed and toothless just like a cat. So they won't even leave their dens and their mom until they're about four to five months old. And even then, they're still pretty dependent on their mom for another eight months after that. Fossas' do not make many noises, but when their mom is around, they do apparently make this really high pitched mewling sound.
And then now, even though they're top predators in Madagascar, unfortunately, there's only about 2, 500 of them left in the wild. So about 90 percent of Madagascar's native forests are gone. So lemurs need those forests in order to be able to survive, and the Fossas' need the [00:28:00] lemurs in order to be able to eat.
So if their main food source is not there, then makes it hard to keep their numbers up. Rabies has also been introduced to the island by dogs and cats, and all mammals can get rabies. Unfortunately, they have gotten rabies. And then lastly, villagers do not like them because now that all of their, their force are gone, they're coming to people's land and then they're killing all of their chickens.
There's also a lot of like folklore around them killing humans and stealing babies and stuff. But because of that, that makes it to where the people of Madagascar don't really want to, keep them around. They are protected from being exported and at least being traded. So if you haven't looked them up yet, definitely look up this really interesting creature. All right, everyone. Thanks for sticking with me through our DKA adventure. And if you have any questions, as always, you can email me at suggs, S U G G S, at Vetsplanationpodcast. com. If you want to donate, you can help keep this [00:29:00] podcast going. We'll provide a link in the show notes. And then next week, we're going to be talking about hypothermia for those really cold months that are coming up. So after that, we'll be talking to Dr. Z about fleas and another episode on ticks. And you might not think that you have to worry about that right now during the winter, but I bet Dr. Z is going to prove us wrong. We're also going to be talking to a vet who works at the Humane Society, super excited to talk to them.
And if you have any suggestions, please email me as well. If you like the way that we do this podcast, you like the layout of it, let me know. If you have something that you feel like we should change because I'd help you learn better, please let me know. I'm always, I'm here to help you guys learn and educate you on everything that goes on with our animals.
All right. So stay tuned for the next couple of weeks to hear more about all of those things. And thank you again. As always, please keep your pets happy, healthy, and safe. Thanks guys.
Thank you guys for listening this week. If you have any questions, comments, suggestions, or you just want to say hi, you can email me at Suggs, S U G G S @ [00:30:00] VetsplanationPodcast.com or visit the website at VetsplanationPodcast.com or find us on Facebook, Instagram, or TikTok at Vetsplanation. Thank you all for listening and I'll see you back here next week.