Page 565 - Cote clinical veterinary advisor dogs and cats 4th

Diabetes, Hyperosmolar Hyperglycemic State 253.e3

Ringer’s solution), provided sodium is not ○ When BG is near 250 mg/dL, add • In people with HHS, the fluid deficit is
reduced too quickly (i.e., < 1 mEq/L/h). ○ BG level should be maintained between assumed to be massive and larger than
dextrose to fluids to create a 5% solution.
VetBooks.ir markedly, and insulin should be avoided Chronic Treatment deficit of 13% is presumed and corrected Diseases and Disorders
○ Fluid therapy alone will reduce BG level
estimated based on clinical signs. Often, a
150-300 mg/dL until the patient is eating.
until hypovolemia is resolved and dehydra-
over 24-48 hours.
tion improved.
○ Because these animals are extremely sick, • After improvement in clinical status, • Hyperglycemia depresses serum sodium
concentration by pulling water out of
oral water intake is unlikely. In addition correction of dehydration and electrolyte cells and diluting the sodium. To estimate
to correction of dehydration, maintenance disturbances, and normalization of BG, the corrected serum sodium value in an
fluids and replacement of ongoing loss conversion to subcutaneous injections for animal with hyperglycemia, add 1.6 mEq/L
(e.g., vomiting, diarrhea) is important. long-term diabetic management can be sodium for every 100 mg/dL serum glucose
• Correct hypokalemia, being mindful to never initiated (p. 251). above the reference range. For example, if
exceed rate of 0.5 mEq/kg/h. • If underlying disease is identified that measured Na = 130 mEq/L and measured
○ Mild hypokalemia (3.0-3.5 mEq/L): add precipitated HHS, it should be addressed glucose = 900 mg/dL, estimated corrected
30-40 mEq KCl per liter to IV fluids directly. Na = 142.8 mEq/L.
○ Moderate hypokalemia (2.5-3.0 mEq/L):
add 40-60 mEq KCl per liter to IV fluids Nutrition/Diet Prevention
○ Severe hypokalemia (<2.5 mEq/L): add Animals cannot be discharged from hospital • Regular veterinary examinations to ensure
60-80 mEq KCl per liter to IV fluids until they are able to receive appropriate good physical health and promote early
○ Even if potassium is normal, hypokalemia nutrition. If an underlying disorder prevents detection of disease concurrent with DM
is anticipated; add 20 mEq KCl per liter voluntary eating of an adequate type and • Periodic BG curves for known diabetics (in
to IV fluids. amount of diet, an esophagostomy tube should clinic or at home) can help ensure appropri-
• Hypophosphatemia is uncommon, but if be considered (p. 1106). ate DM management.
phosphorous < 1.5 mg/dL, especially with
concurrent anemia, supplement at 0.01- Possible Complications Technician Tips
0.03 mmol/kg/h in calcium-free fluids. Rapid decline or change in mental status can • Known diabetics with illness or anorexia
• Begin insulin therapy only after patient is indicate cerebral edema. should have BG concentration determined.
rehydrated. Short-acting insulin therapy (e.g., If a glucometer reading is “too high to read,”
regular insulin) should be administered by a Recommended Monitoring a quantitative BG should be assessed.
constant-rate infusion (CRI) or intermittent • Blood pressure, BG, electrolytes, and packed • Obtain a urine sample from all diabetic
IM injections. The goal of insulin therapy is cell volume (PCV) should be checked regu- patients before initiation of treatment to
a steady decrease in BG levels of 50-75 mg/ larly throughout hospitalization. BG should assess glucose, ketones, and urine specific
dL/h. Declines that exceed this rate can lead be checked every 2-4 hours and adjustments gravity and for urine culture.
to cerebral edema. to insulin therapy made accordingly until the
• Placement of two catheters, a central line animal is eating and can be transitioned to Client Education
for frequent blood sampling as well as a longer-acting insulin. • All geriatric pets should be seen at least
another for fluid administration, is ideal. • Recommended monitoring to prevent future annually by a veterinarian.
The second catheter can be used for an episodes of HHS includes achieving and • Regular monitoring can help ensure proper
insulin CRI. If regular insulin is to be maintaining diabetic control. diabetic control.
administered by CRI, discard the first 50 mL • Diabetic pets that display any signs of illness,
of the prepared solution that has been run PROGNOSIS & OUTCOME including anorexia, vomiting, diarrhea, or
through the line as insulin adheres to the changes in mentation, should be seen as soon
tubing. • Prognosis is poor to guarded and ultimately as possible.
• A CRI can be prepared by adding 2.2 U/kg depends on severity of metabolic derange- • Treatment of HHS is complicated and costly
(dogs) or 1.1 U/kg (cats) of regular insulin ments, neurologic deficits, and concurrent with a guarded prognosis.
to 250 mL of 0.9% saline. Insulin CRIs disease. Overall survival rate is 50%-60%
are often run through a line separate from with aggressive therapy. SUGGESTED READINGS
replacement fluids. Adjust the administration • Prognosis is negatively impacted by abnormal Koenig A, et al: Hyperglycemic, hyperosmolar
rate based on BG as follows: mental status, coma, and low venous pH at syndrome in feline diabetics: 17 cases (1995-2001).
○ 10 mL/h if BG > 250 mg/dL presentation. J Vet Emerg Crit Care 14:30-40, 2004.
○ 7 mL/h if BG 200-250 mg/dL; add 2.5% Trotman TK, et al: Retrospective evaluation of
dextrose to replacement fluid PEARLS & CONSIDERATIONS hyperosmolar hyperglycemia in 66 dogs (1993-
○ 5 mL/h if BG 150-200 mg/dL; add 2.5% 2008). J Vet Emerg Crit Care 5:557-564, 2013.
dextrose to replacement fluid Comments
○ 5 mL/h if BG 100-150 mg/dL; add 5% • Affected animals are extremely ill and require RELATED CLIENT EDUCATION
dextrose to replacement fluid almost constant initial monitoring with fre- SHEETS
○ Stop insulin CRI if BG < 100 mg/dL; quent reassessment of laboratory parameters.
add 5% dextrose to replacement fluid Whenever possible, they should be referred to Diabetes Mellitus (Cats)
• An intermittent IM protocol can also be a practice with 24-hour, critical care facilities. Diabetes Mellitus (Dogs)
used. • Avoid rapid correction of BG and electrolyte How to Administer and Handle Insulin
○ Initial dose of 2 units regular insulin for levels because this may result in exacerbation How to Monitor Blood Glucose Levels at Home
cats and dogs less than 10 kg, 0.1-0.2 mg/ of neurologic signs. Ultimately, low-sodium AUTHOR: Erin Rogers, DVM
kg for dogs greater than 10 kg fluids (half-strength saline, 5% dextrose) are EDITOR: Ellen N. Behrend, VMD, PhD, DACVIM
○ Then administer 0.05-0.1 mg/kg q 4-6h not recommended because this may result
until BG between 200-250 mg/dL. in rapid decline in sodium levels.

www.ExpertConsult.com