Changes

Animals presenting with DKA are often collapsed, comatose and severely dehydrated.  Stabilisation would involve the following aspects of care:

Animals presenting with DKA are often collapsed, comatose and severely dehydrated.  Stabilisation would involve the following aspects of care:

*'''Intra-venous fluid therapy''' with a suitable product. The priorities of fluid therapy are to hydrate the animal and prevent further damage due to poor tissue perfusion and to provide sodium which will have been lost with the osmotic diuresis.  With the latter aim in mind, 0.9% sodium chloride solution is recommended.  Other clinicians prefer to use compound sodium lactate (Hartmann's solution) as it provides some buffering capacity and, because its potassium content is much lower than that of normal plasma, it is unlikely to worsen any hyperkalaemia.  Fluid deficits should be replaced over 24 hours and fluids should not be infused at rates much above twice maintenance to prevent cerebral oedema for occurring due to rapid alterations in electrolyte concentrations.  It would also be advisable to measure serum electrolyte concentrations regularly to prevent this effect from occurring.

*'''Intra-venous fluid therapy''' with a suitable product. The priorities of fluid therapy are to hydrate the animal and prevent further damage due to poor tissue perfusion and to provide sodium which will have been lost with the osmotic diuresis.  With the latter aim in mind, 0.9% sodium chloride solution is recommended.  Other clinicians prefer to use compound sodium lactate (Hartmann's solution) as it provides some buffering capacity and, because its potassium content is much lower than that of normal plasma, it is unlikely to worsen any hyperkalaemia.  Fluid deficits should be replaced over 24 hours and fluids should not be infused at rates much above twice maintenance to prevent cerebral oedema for occurring due to rapid alterations in electrolyte concentrations.  It would also be advisable to measure serum electrolyte concentrations regularly to prevent this effect from occurring.

*'''Insulin''' should be provided to reverse the metabolic changes that have resulted in the crisis.  Since the administration of insulin may also have marked consequences for electrolyte status, it is best to administer it gradually as an infusion of soluble insulin.  The insulin solution (made up in 0.9% sodium chloride) should be administered through a separate fluid line to that used for conventional fluids and the solution should be run through this line to saturate the bindings sites along the plastic with insulin molecules.  Blood glucose concentration should be measured every regularly.  Alternatively, intermittent injections of insulin may be used at hourly intervals while also measuring the blood glucose concentration.

*'''Insulin''' should be provided to reverse the metabolic changes that have resulted in the crisis.  Since the administration of insulin may also have marked consequences for electrolyte status, it is best to administer it gradually as an infusion of soluble insulin.  The insulin solution (made up in 0.9% sodium chloride) should be administered through a separate fluid line to that used for conventional fluids and the solution should be run through this line to saturate the bindings sites along the plastic with insulin molecules.  Blood glucose concentration should be measured regularly.  Alternatively, intermittent injections of insulin may be used at hourly intervals while also measuring the blood glucose concentration.

It is important that insulin is not administered too quickly because it causes both potassium and phosphate to move intracellularly with glucose.  This can result in rebound hypoglycaemia, hypokalaemia, hypophosphataemia and hypomagnesaemia because the total body levels of these cations will probably have been reduced by the enforced osmotic diuresis).  Severe hypophosphataemia may result in the development of haemolytic anaemia.  Potassium may need to be supplemented from the outset and the rate at which insulin is administered should be reduced if the animal is hypokalaemic on presentation.  Other electrolytes should only be supplemented after their serum levels have been measured.

It is important that insulin is not administered too quickly because it causes both potassium and phosphate to move intracellularly with glucose.  This can result in rebound hypoglycaemia, hypokalaemia, hypophosphataemia and hypomagnesaemia because the total body levels of these cations will probably have been reduced by the enforced osmotic diuresis).  Severe hypophosphataemia may result in the development of haemolytic anaemia.  Potassium may need to be supplemented from the outset and the rate at which insulin is administered should be reduced if the animal is hypokalaemic on presentation.  Other electrolytes should only be supplemented after their serum levels have been measured.

*'''Infections''' occur frequently, either as a cause or effect of DKA.  Broad spectrum bactericidal antibiotics are generally recommended in all cases.

*'''Infections''' occur frequently, either as a cause or effect of DKA.  Broad spectrum bactericidal antibiotics are generally recommended in all cases.