29 | The 6 things you need to know to understand diabetic ketoacidosis

DKA patients vary from patients with mild ketosis and dehydration all the way to collapsed, severely unwell patients in shock, with marked acidosis and needing intensive nursing care.

However these patients present, one thing remains true - there is a LOT of nursing care we can provide. But to do that, we need to understand how DKA works and what care our patients need - and that’s exactly what we’re diving into in this episode.

But before we do…

I want to remind you that on July 10th, I’m hosting a webinar that you won’t want to miss! 

In ‘Demystifying Diabetes, ‘ we’ll discuss what diabetes is, how it affects our patients, the signs we see, and the tests our patients need. 

We’ll examine treatment and monitoring in-depth, including brand-new treatments like Senvelgo and advanced monitoring options like HbA1C and glucose monitoring sensors.

Most importantly, you’ll leave knowing exactly what to consider when nursing these patients—from fluid therapy and acid-base and insulin CRIs to feeding plans and vascular access, advising clients, and much more.

Tickets are just £25 and include the live session, recording, slides, worksheets and handouts, a quiz, and a CPD certificate.

If you want to feel confident and really enjoy nursing your diabetic patients while using new practical skills your patients will benefit from, make sure you’re there! You can reserve your spot here or DM me on Instagram to chat more about whether it’s right for you. I can’t wait to see you there!

So, what is DKA?

DKA is a common complication of decompensated DM. It’s a serious condition associated with significant morbidity and mortality.

It can be seen in previously undiagnosed diabetic patients or in existing diabetics with concurrent diseases impacting their glycaemic control.

In fact, in one study, DKA occurred in 65% of newly diagnosed diabetic dogs, and around 70% of DKA patients were reported to have concurrent diseases (such as pancreatitis) at the time of presentation.

DKA is defined as a combination of hyperglycaemia, glucosuria, ketonaemia, ketonuria, and metabolic acidosis. Technically, we need glucose, ketones, and confirmed metabolic acidosis to diagnose DKA. 

So, how does DKA happen?

Diabetic patients are hyperglycaemic since they lack insulin, which allows glucose to enter cells and be used as an energy source (as well as stored in the liver as glycogen). 

Insulin also works against counter-regulatory hormones: substances in the body that can increase blood glucose levels when needed (e.g. in response to hypoglycaemia or when in a ‘fight or flight’ situation where extra energy may be required). These substances include things like cortisol, glucagon and adrenaline. They are often secreted when the patient is under significant stress or when the body is under stress - e.g., during periods of illness or general anaesthesia.

Not only do patients with DKA lack sufficient insulin to use glucose as an energy source, but they’re often systemically unwell, with increases in those counter-regulatory hormones causing worsening hyperglycaemia. Despite having higher glucose levels, the body still can’t use that as energy since insulin is required for that process.

As a result, the body searches for alternative energy sources to glucose—and to do this, it turns to fat. Fat cells are broken down into free fatty acids, which the liver converts into ketone bodies.

These ketones can be used as an emergency energy source. There are three different ketone bodies - beta-hydroxybutyrate, acetone and acetoacetate- and two are acidic.

The accumulation of these ketone bodies causes ketosis and metabolic acidosis. In addition, as hyperglycaemia continues, so does the ongoing cycle of ketone formation. This causes glucosuria and ketonuria, increased fluid losses via urine due to osmotic diuresis, and dehydration.

And what signs do we see with DKA?

The most common clinical signs of DKA are depression, anorexia and vomiting alongside PUPD. The severity of these signs can vary - some patients will present severely unwell, collapsed with profound mentation changes and hypovolaemia, whereas others will have milder signs with only PUPD noted - especially if they are an existing diabetic where clients are used to monitoring them more closely..

We know that DKA doesn’t just happen in undiagnosed diabetics - often, patients with a previous DM diagnosis get DKA due to concurrent diseases impacting their glycaemic control. 

A classic example of this is pancreatitis - and where other diseases are present, so too will be other clinical signs—for example, severe abdominal pain, anorexia and vomiting.

If you’ve got the gene, you can also smell ketones on your DKA patient’s breath - I don’t myself, but people with the power reliably tell me it smells like pear drops (sweets) or like nail polish remover (since that’s also what acetone, one of the ketone bodies, is!)

You think your patient has DKA - what next?

Several diagnostic tests are performed to confirm the condition, investigate any concurrent or contributing diseases, and assess the patient’s current health status. These include a full biochemistry, haematology, ketone assessment, urine analysis, and diagnostic imaging, alongside blood gas analysis (if you have it available) and potentially other tests, like PLi measurement.

Biochemistry and haematology

Biochemistry allows us to evaluate organ function, detect contributing diseases, confirm the presence of hyperglycaemia and evaluate the degree of electrolyte disturbance present. 

We’ll also add ketone measurement (if you have access to a ketone meter) and may add other tests like pancreatic lipase assessment if you want to rule in or out pancreatitis as a possible cause of DKA.

Haematology allows us to look for evidence of infection or inflammation and assess the degree of haemoconcentration present secondary to fluid losses.

Urine analysis 

If possible, urine analysis should include a dipstick, specific gravity, sediment examination, and culture. 

Urinary tract infections are common in diabetic patients since glucose in the urine acts as a food source for bacteria - and UTIs can interfere with diabetic control and trigger DKAs in existing diabetics.

We’ll see glucosuria and likely ketonuria on our urine dipstick, but be aware - one of those ketone bodies, beta-hydroxybutyrate, does not show up on urine dipstick testing, so it is possible for a patient to have a negative urine dipstick and still have ketones present.

Blood gas analysis

If you have access to blood gas analysis in practice, this should be performed. A venous sample is fine, and this allows us to look at blood pH, anion gap, and bicarbonate levels and measure osmolarity, which is essential in DKA patients who are often hyperosmolar.

Technically, we need to confirm that metabolic acidosis is present to say our patient has DKA - so if you can, measure blood gases!

So, your patient has DKA. How will you treat them?

Our main treatment goals are to restore hydration and electrolyte imbalance, stop ketogenesis (the formation of ketones), and correct acid-base imbalances.

Let’s look at fluid therapy, electrolytes and acid-base first

The first thing we want to do is provide fluid therapy. Total requirements should be calculated to correct dehydration, replace maintenance needs, and account for ongoing losses.

An appropriate crystalloid solution should be selected. Potassium supplementation is also often needed (either on presentation or during hospitalisation), sometimes in high concentrations, because the patient either has potassium losses on presentation or will develop them during treatment with insulin. 

Phosphate levels can also change in response to insulin therapy and may need supplementing.

And what about insulin?

Neutral or regular insulin is used in DKA. This rapid-onset, short-acting insulin reverses ketone formation whilst reducing hyperglycaemia.

It’s either given as a CRI, which is the preferred method or via intermittent IM injection if that isn’t possible. We adjust the CRI rates and doses based on the patient’s blood glucose levels, which we measure hourly.

We aim to maintain the patient’s blood glucose levels within the 8-14 mmol/L range until they are persistently ketone-negative. If they drop below 8-11mmol/L but are still ketone-positive, we must add a dextrose CRI to maintain normoglycaemia.

Once the patient is persistently ketone negative, their hydration status has normalised, and they are eating consistently, they are transitioned to longer-acting insulin.

What about nursing these patients?

Alongside intensive monitoring and providing supportive care, nutrition, vascular access, and client education are vital areas for the veterinary nurse or technician to consider.

Let’s look at nutrition

Nausea and vomiting are often present in DKA, and that, combined with how rubbish they feel in themselves, is going to mean they’re even less likely to want to eat for us. 

Nutrition is an essential aspect of nursing for all patients, and DKA is no exception. If they’ve been anorexic for two days, consider getting a feeding tube in and begin refeeding them carefully with an appropriate diet.

And what about vascular access?

Vascular access is another vital consideration in DKA. These patients often require frequent sampling—not just for glucose measurement (which can easily be achieved in a much more patient-friendly way by using a continuous glucose monitor) but also to check things like electrolytes and blood gases regularly.

A central venous catheter is a great option for these patients since we can sample from it while also providing reliable long-term venous access. If you don’t have access to one, consider a PICC line—a peripherally inserted central catheter—which is very similar but much easier to place and maintain.

And then there’s client care…

Client education and support are essential at any point in a diabetic patient’s life, but starting this during the DKA stage is essential.

Suppose they’ve not already been diagnosed with diabetes. In that case, this patient will become a long-term diabetic and need ongoing care - and adjusting to a new diabetes diagnosis a challenging time for our clients! On top of that, the prognosis for DKA can be guarded, and they’ll be dealing with the fact their pet is severely unwell.

So start your nursing support early and then continue that support for the rest of their pet’s life. Not only will your clients (and vet team) thank you for it, but you’ll also make an enormous difference to your patients and get more job satisfaction while you’re at it!

So there you have it! A whistle-stop tour of managing diabetic ketoacidosis in dogs and cats. Yes, DKA is a common and often complicated disease requiring intensive management and lots of nursing care, but we also make an enormous difference not just to these patients but to their families as well.

And after their DKA, we get to manage them as a ‘normal’ diabetic for the rest of their life - meaning we get to continue providing more support and using more of our nursing skills.

Did you enjoy this episode? If so, I’d love to hear what you thought - screenshot it and tag me on Instagram (@vetinternalmedicinenursing) so I can give you a shout-out and share it with a colleague who’d find it helpful!

Thanks for learning with me this week, and I’ll see you next time!

References and Further Reading

• Fay, C. 2023. Diabetic ketoacidosis in emergency and critical care [Online] Veterinary Practice. Available from: https://www.veterinary-practice.com/article/diabetic-ketoacidosis-in-emergency-and-critical-care

• Kipperman, B. and Rogers, B. 2012. Endocrinology. In: Merrill, L. ed. Small Animal Internal Medicine for Veterinary Technicians and Nurses. Iowa: Wiley-Blackwell, pp. 11 - 68.

• Nelson, R W. and Couto, C G. Small Animal Internal Medicine. 5th ed. Missouri: Elsevier Mosby, 2014.

• Tabor, B. 2019. Understanding and Treating Diabetic Ketoacidosis. VetFolio, available from: https://www.vetfolio.com/learn/article/understanding-and-treating-diabetic-ketoacidosis