You know what?! There is NOTHING I love more than getting stuck into a good DKA case. Let me tell you why:

Because the reality is, we can use SO many different skills to help them. And not only do these skills allow us to nurse our patients more effectively - improving the patient’s experience in the hospital - but they actually allow us to do more, too!

And that’s something I know we all want - every nurse and technician should be able to be used to their fullest potential. Any skill we can perform, but aren’t performing in our clinics, are such a waste of our RVN/VT qualification!

Last month, I introduced my VIP list to Bobby - a 13-year-old Border Terrier with previously stable diabetes (and a few other comorbidities, because he’s a medicine patient!) who had presented as an emergency in DKA.

In this post, we’ll learn together exactly how to nurse him - planning care that will actually make a difference to him in hospital, whilst boosting the skills we can perform with him!

Need a refresher on his case? Let’s take a look…

Meet Bobby

Bobby is a 13-year-old MN Border Terrier.

He’s previously been seen at your clinic for management of previously stable diabetes mellitus, osteoarthritis, chronic pancreatitis, and cataracts.

Today, though, he’s presented to the vet for an urgent appointment with a 2-day history of anorexia, lethargy, weakness and intermittent vomiting. Because he hasn’t been eating, his family haven’t given him any insulin for the last 36 hours.

He is severely unwell on presentation, so the vet brings him straight through for stabilisation.

Examination

You assist the vet with Bobby’s examination and initial treatment, and find that:

• Bobby is dehydrated with obvious skin tenting, sunken eyes and tacky mucous membranes

• He also appears hypovolaemic, with tachycardia (140 beats/minute), poor quality pulses and a CRT of 2-3s

• He was carried through so you’re unable to assess ambulation, but he is in lateral recumbency on the examination table so you suspect he is recumbent

• He is panting, but otherwise stable respiratory-wise, with normal auscultation and effort

• He is mildly hypothermic at 37*C

• He appears uncomfortable on palpation of his cranial abdomen

• He weighs 8.2kg.

Stabilisation and Initial Results

The vet asks you to place an IV catheter, check an emergency blood panel (glucose, ketones, PCV/total solids and a venous blood gas) and begin a 10ml/kg bolus of Lactated Ringer’s solution over 10 minutes.

On Bobby’s results, you find he is:

• Hyperglycaemic (glucose ‘Hi’ on glucometer)

• Ketonaemic (ketones 3.8mmol/L, reference range 0-0.3)

• Haemoconcentrated (PCV 50%, TS 90g/L)

• Acidotic (pH 7.2, with low base excess and bicarbonate, indicating a metabolic acidosis)

You administer Bobby’s fluid bolus, and begin seeing improvements in his cardiovascular status. After a further bolus, he appears significantly improved, and you’re able to settle him in a kennel and implement his longer-term treatment plan.

Bobby’s Treatment

The vet asks you to begin the following treatment plan for Bobby’s DKA:

• Neutral insulin via CRI, rates dependent on blood glucose level (if BG levels drop below 8mmol/L, begin dextrose supplementation alongside insulin CRI until persistently ketone negative)

• Fluid therapy with LRS at maintenance + 6% dehydration over the next 24 hours, then reassess fluid rate

• Supportive treatment with maropitant (1mg/kg IV q24 hours) and capromorelin (3mg/kg PO q 24 hours)

• Pain assessments and analgesia (methadone vs buprenorphine as required) depending on pain scores

• Blood samples hourly for BG levels (ear pricks)

• Bloods every 12 hours for electrolytes and venous blood gas analysis

You’re also asked to place a naso-oesophageal feeding tube and begin feeding Bobby with a low-fat GI liquid diet at 1/3rd RER.

Bobby is now no longer hypovolaemic and settled in his kennel. You’ve started his neutral insulin CRI and administered his initial maropitant and IV fluids, so now we need to plan the nursing care he’ll benefit from.

So how will we do this? Let’s take a look 👇🏼

Bobby’s Nursing Care

Nutritional Status and Appetite Support

We know that Bobby is diabetic and has a history of pancreatitis, and that he’s been anorexic for 2 days on presentation - so we’ll need to intervene as a priority.

Going down the ‘tempting’ route (instead of the ‘tube’ route) isn’t going to be suitable in his case - because in order to get insulin into him reliably, plus provide enough calories and nutrition to his enterocytes, we’ll need him to be eating sufficient amounts voluntarily.

Given he’s pretty uncomfortable and nauseous, it’s unlikely he’ll want to eat enough without some assistance. So alongside treating any pain and nausea - since these will contribute to his anorexia - we’ll also administer food via the NO tube we placed earlier.

These are super quick and easy to place, and very well tolerated in most cases - so a great option for anorexic inpatients. In Bobby’s case, we’ll create a feeding plan for him starting at 1/3rd of his RER - so let’s do that now:

1. RER = 70 x (8.2^0.75) = 339 kcal/day

2. Day 1 = 1/3rd RER = 340 / 3 = 112kcal on day 1

3. Day 2 = 2/3rd RER = 112 x 2 = 226kcal on day 2

4. Day 3 onwards = full RER = 339kcal each day

GI Low Fat Liquid is 1kcal/ml, so he’ll need 112ml on day 1, 226ml on day 2, and 339ml on day 3 and beyond.

Next up, we need to think about meal timings. Bobby is usually fed four times a day at home; larger meals at the time of his insulin injections, and then smaller meals in between.

At the moment, he’s on an insulin CRI with us, so it’s unlikely we’ll significantly impact things too much with feeding schedule. We’ll go for even meals every 6 hours to start off, and see how he responds:

• Day 1: 28ml every 6 hours (QID)

• Day 2: 56ml every 6 hours (QID)

• Day 3 onwards: 84ml every 6 hours (QID)

We would likely avoid feeding less frequently than this, since his volumes per feed on day 3 are very similar to gastric capacity (approx 10ml/kg).

Alongside tube feeding, we’ll offer Bobby food by mouth (prioritising low fat options) at the time of each feed, tempting him and recording calories consumed voluntarily. We can then reduce his tube feed by that much, so we’re not overfeeding.

On top of feeding, nutritional monitoring is an important nursing consideration. So we’ll monitor his bodyweight and body and muscle condition scores closely, re-weighing him at least every 24 hours.

Hydration Status and Fluid Balance

Bobby is hypovolaemic on presentation; this is a potentially life-threatening drop in his intravascular (circulating) volume. This has been corrected with crystalloid boluses, so careful monitoring of his perfusion parameters (heart rate, blood pressure, MM colour, CRT and pulse quality) is indicated going forwards.

We also need to make an appropriate hydration plan for Bobby. His boluses have stabilised his circulating losses, but he’s still 6% dehydrated - and this needs to be corrected more slowly.

We’ll also need to cover his daily maintenance fluid requirements on top of this.

So how do we do that? Well, if we take maintenance as 2ml/kg/hour (other formulas can also be used, but this is what we did in his case), it looks a bit like this:

•  6% x 10ml/kg x 8.2kg = 492ml fluid deficit

• Corrected over 24 hours = 492ml / 24hr = 20.5ml/hour

• Plus maintenance at 2ml/kg/hour = 2ml/kg/hour x 8.2kg = 16.2ml/hour

• 20.5ml/hour + 16.2ml/hour = 36.7ml/hour

After 24 hours, we’ve corrected the dehydration - so Bobby’s current fluid rate would then put him at risk of overload. We need to assess him again and adjust his fluid rate as needed, to cover maintenance, plus any ongoing abnormal fluid losses (eg polyuria, diarrhoea or vomiting).

To assess hydration, we need to be monitoring his skin tenting, how tacky his MMs are, and whether his eyes appear sunken or dull. However, we can see no clinical signs (or very mild ones) all the way up to 5% dehydration, so we need to be watching these patients closely, and thinking of alternative ways to assess hydration.

A quick and simple one is to weigh patients more regularly - since most acute weight changes are associated with changes to fluid balance.

Along with hydration status, electrolyte and acid-base balance are also important considerations in Bobby’s case. He’s got metabolic acidosis - which will improve by administering balanced cyrstalloid solutions (LRS) and reducing his ketone levels. But he’s also at risk for developing hypokalaemia during his insulin CRI, since insulin drives potassium into cells. This means that regular sampling is indicated, and we will likely need to add extra potassium to his fluids.

Recumbency Considerations, Mobility and Eliminations

Bobby is recumbent right now, due to the severity of his condition on presentation. We don’t anticipate that he’ll remain recumbent for long (hopefully!), but we do need to think about how this will impact his nursing care.

First up - let’s think about urination. He’s polyuric because of his hyperglycaemia, so we know he’ll be urinating more, and so at a higher risk of scalding during recumbency.

However, he’s also at increased risk for UTIs, since he has glucosuria - so i wouldn’t be rushing to place an indwelling urinary catheter in his case. Instead, we’ll do what we can to keep him clean, apply barrier cream if needed, consider bladder expression to help keep him comfortable, and use plenty of wicking bedding on top of any absorbent material.

Bobby is also arthritic, and his recumbency isn’t going to be helping that. Regular massive, passive range of motion, and supported exercise (once he’s clinically well enough to start moving around again) would all be beneficial.

Vascular Access and Sampling

Bobby is having multiple IV fluids and medications. He’s on an insulin CRI, normal IV fluids, and a whole host of supportive meds.

On top of that, he may need a dextrose CRI, and we might have to think about some potentially high rates of potassium supplementation, too.

Potassium in high concentrations (>40mmol/L) should ideally run through a large vessel such as the jugular vein. For this reason, AND the benefits of sampling - which we’ll chat about in a second - we’d thinking about placing a central venous catheter in his case. These allow us to administer many solutions simultaneously, and can be used to collect blood samples directly from the cranial vena cava.

If you’re not in a practice that uses these, there is an alternative which is less invasive - a PICC line. These can again be used for sampling, and can be placed very quickly and easily by nurses and technicians.

Speaking of sampling, we’ll need to do a lot of it - hourly glucose monitoring, and samples every 12-24 hours for blood gases and electrolytes. So having the ability to get blood samples easily without poking a vein is really going to improve Bobby’s experience in the clinic.

Options for Glucose Monitoring

Bobby, as we’ve just said, needs a LOT of bloods. And whilst we’ve (hopefully) now got a catheter in place which will help with this, I wouldn’t be using this for his hourly BGs.

Why? Because I’d be a little worried about drawing too much off, and making him anaemic.

We only need one drop of blood for his BG - and you’ll likely find it tough to pull that small a volume from a central or PICC line.

Instead, we can either take hourly ear prick samples, OR consider placing a continuous glucose monitor. If we’re going down the CGM route, we need to make sure that Bobby is well hydrated, since these devices measure glucose levels in the interstitial fluid.

Pain Assessment and Analgesia

Bobby has not just chronic pancreatitis, but osteoarthritis, too. Both of these conditions are painful - he’s in chronic pain from his OA, and has had a more acute flare-up of his pancreatitis on top.

We need to be monitoring his pain levels (tools like the Glasgow pain scale are good for acute pain in dogs, and the Helsinki chronic pain index and CBPI scales are options for chronic pain).

Of course, we’ll continue Bobby’s opioids (methadone or buprenorphine, as needed depending on our assessments), and adjust doses as required.

Lastly - we also need to think about Bobby’s restraint. If he’s arthritic, he may not tolerate having a forelimb extended for an IV, for example. So we want to assess this, and work within his limits to comfortably perform minor procedures like sample collection, or catheter placement.

Diabetic Care, Education and Management

Finally - don’t forget that at the end of his DKA, he’s going to revert back to being a “normal” diabetic - and there are LOTS more opportunities to help here too!

Nurses are ideally placed to be educating clients, answering queries, performing repeat examinations and collecting samples for the vets - as well as providing advice.

So there you have it - all of this (and more!) is why I LOVE diabetics so much. Because which other patients have got you calculating CRIs, placing central lines and feeding tubes, calculating fluid rates and nutritional plans, and then providing long-term support too?

The more we can do to get hands-on with our medical patients, the more we (and they!) will benefit.

Did I miss anything on your list? DM me on Instagram and let me know!