Pathophysiology and aetiology of hypoglycaemic crises

Influence of hospital-induced stress on blood glucose concentrations, serum concentrations of cortisol, thyroxine and bile acids, and behaviour in cats

ObjectivesStress-induced transient hyperglycaemia may complicate the diagnosis of disease-related hyperglycaemia in cats during hospital visits. This study aimed to define the optimal acclimatisation period for reliable blood glucose measurements and determine the effect of hospital stress on physiological (heart rate [HR] and respiratory rate [RR]), behavioural (Cat Stress Score [CSS]) and metabolic (glucose, cortisol, total thyroxine [TT4] and bile acids [BA]) variables in cats.MethodsA total of 10 healthy cats were evaluated at home and during hospitalisation. Blood glucose was measured hourly for 10 h after withholding food. HR, RR and CSS were determined at T01, T04 and T10. Serum cortisol, TT4 and BA were evaluated at T01 and T10.ResultsStress-induced hyperglycaemia was observed in the hospital. The acclimatisation cut-off time for the cats' return to euglycaemia was 6 h. Cats with hyperglycaemia had a higher CSS than cats with euglycaemia (P <0.001). Elevated HR, RR, CSS, glucose and cortisol concentrations were observed in cats at the hospital compared with those at home (P <0.001), while BA concentrations were significantly lower at the hospital (P <0.001). Significant interactions between time and place were identified for CSS, cortisol, BA concentrations (P <0.001) and glucose (P = 0.009). Notably, CSS and concentrations of cortisol remained stable when the cats were at home but decreased over time in the hospital. Conversely, BA concentrations were stable during the period in the hospital but decreased over time at home. There was a moderate positive correlation for serum cortisol and CSS (ρ = 0.6621; P <0.001) and for blood glucose (ρ = 0.4999, P <0.001).Conclusions and relevanceStress from hospital visits impacts clinical and laboratory results in cats. Our study would suggest that healthy cats that experience stress-induced hyperglycaemia should be acclimatised for at least 6 h before re-evaluation. Similar studies in sick cats should be conducted.

Recognising and managing hypoglycaemia in adults with diabetes in the emergency department

Hypoglycaemia is a common cause of presentation to the emergency department (ED) for people with diabetes mellitus. Patients experiencing a hypoglycaemic episode require prompt treatment with fast-acting glucose to prevent brain fuel deprivation and functional brain failure, therefore it is vital that ED nurses can recognise the signs and symptoms of hypoglycaemia and are aware of the factors that can compound or mask it. This article discusses the aetiology and signs and symptoms of hypoglycaemia in adults with type 1 and type 2 diabetes and describes the use of an algorithm for the management of hypoglycaemia in this patient population in hospital. The author also discusses how ED nurses can try to identify the cause of the hypoglycaemic episode and work with patients, their relatives or carers and the wider multidisciplinary team to prevent reoccurrence.

PROFOUND HYPOGLYCEMIA AND BLOOD GLUCOSE TESTING METHODOLOGIES IN FLORIDA MANATEES (TRICHECHUS MANATUS LATIROSTRIS) PRESENTED TO A CRITICAL CARE CENTER

Florida manatees (Trichechus manatus latirostris) continue to experience pressure from various stressors that frequently result in the need for rescue and veterinary assistance. Interestingly, a subset of rescued manatees in critical condition exhibits profound hypoglycemia. The goals of this study were to enhance our understanding of this important aspect of manatee care by 1) characterizing the clinical presentation and factors associated with manatees that present with profound hypoglycemia, and 2) assessing agreement across blood glucose testing modalities [glucometer (whole blood), in-house bench-top analyzer (whole blood), a point of care analyzer (whole blood), and a local human hospital laboratory analyzer (serum)]. Twenty-five manatees were admitted to the Jacksonville Zoo and Gardens from 2017 to 2021. Seven manatees were profoundly hypoglycemic on presentation with blood glucose concentrations of < 30 mg/dL. Hypoglycemic manatees were admitted due to cold stress syndrome (n = 3; 1 calf, 2 adults) or emaciation consistent with an unusual mortality event (n = 4; 2 calves, 2 adults). Physical examination findings in hypoglycemic animals included emaciation (n = 7, 100%), lethargy (n = 7, 100%), and intermittent mild muscle fasciculations of the muzzle (n = 3, 42.8%). Hypoglycemia resolved with intense supportive care and monitoring in all affected animals within 32 h of admission. No associations were identified between hypoglycemia on presentation and life-stage, sex, transport distance to JZG's critical care facility, or rehabilitation outcome (death/euthanasia vs. release). Statistical agreement was observed between all blood glucose testing modalities except for the glucometer vs. the human hospital analyzer. Despite the limited sample size, these findings inform on the clinical presentation of severe hypoglycemia, the importance of close blood glucose monitoring after admission, blood glucose testing modalities, and clinical decision-making in Florida manatees admitted to critical care centers.

Basic triage in dogs and cats: Part III

Background

Emergency cases can be presented at any time of the day or night. All small animal practitioners need to have the skills to triage and stabilize common emergency cases, even if the ultimate goal is to refer the animal to another facility.

Objective and procedure

The third and final part of this 3-part review article series discusses arrhythmias typical in emergency cases and the approach to animals that are presented with an inability to stand up and walk normally. A stepwise method to categorize and stabilize these cases is outlined, along with helpful tips to optimize the referral experience, if indicated.

Results

Recognizing and knowing how to treat tachy- and bradyarrhythmias is important in stabilizing a dog's or cat's condition. Understanding how to differentiate the various reasons that a dog or cat is unable to stand on its own allows a veterinarian to both treat and communicate outcome expectations for those animals.

Conclusion and clinical relevance

Do not refer emergent cases before basic stabilization is completed. Many emergency cases can either be worked up by the primary veterinarian or sent to a referral clinic on an appointment basis after appropriate stabilization steps have occurred.

Basic triage in dogs and cats: Part II

Background

Emergency cases can be presented at any time of the day or night. All small animal practitioners need to have the skills to triage and stabilize common emergency cases, even if cases are ultimately referred to another facility.

Objective and procedure

The second part of this 3-part review article series discusses animals that collapse at home as well as dogs and cats with bleeding. A stepwise approach to categorize and stabilize these cases is outlined, along with helpful tips to optimize the referral experience, if indicated.

Results

Having a robust and methodical approach to animals that collapse is important for many emergency cases, as the causes and treatment methods vary. Bleeding can lead to acute death if left untreated and knowing the steps to stop bleeding is important for patient stabilization.

Conclusion and clinical relevance

Do not refer emergent cases before completing basic stabilization. Many emergency cases do not require emergent referral and can be worked up by the primary veterinarian or sent to a referral clinic on an appointment basis after appropriate stabilization steps have occurred.

A review of the pharmacology and clinical applications of levetiracetam in dogs and cats

OBJECTIVE

To review and summarize the pharmacology of the antiepileptic drug (AED), levetiracetam (LEV), and to discuss its clinical utility in dogs and cats.

DATA SOURCES

Veterinary and human peer-reviewed medical literature and the authors' clinical experience.

SUMMARY

LEV is an AED with mechanisms of action distinct from those of other AEDs. In people and small animals, LEV exhibits linear kinetics, excellent oral bioavailability, and minimal drug-drug interactions. Serious side effects are rarely reported in any species. LEV use is gaining favor for treating epilepsy in small animals and may have wider clinical applications in patients with portosystemic shunts, neuroglycopenia, and traumatic brain injury. In people, LEV may improve cognitive function in patients with dementia.

CONCLUSION

LEV is a well-tolerated AED with well-documented efficacy in human patients. Although its use is becoming more common in veterinary medicine, its role as a first-line monotherapy in small animal epileptics remains to be determined. This review of the human and animal literature regarding LEV describes its role in epileptic people and animals as well as in other disease states and provides recommendations for clinical usage.

Clinical features, risk factors, diagnosis, and treatment of trimethoprim-sulfamethoxazole-induced hypoglycemia

OBJECTIVE

Hypoglycemia is a sporadic and serious adverse reaction of trimethoprim-sulfamethoxazole (TMP-SMX) due to its sulfonylurea-like effect. This study explored the clinical characteristics, risk factors, treatment, and prognosis of TMP-SMX-induced hypoglycemia.

METHODS

Case reports and series of TMP-SMX-induced hypoglycemia were systematically searched using Chinese and English databases. Primary patient and clinical information were extracted for analysis.

RESULTS

A total of 34 patients were reported from 31 studies (16 males and 18 females). The patients had a median age of 64 years (range 0.4-91), and 75.8% had renal dysfunction. The median duration of a hypoglycemic episode was six days (range 1-20), and the median minimum glucose was 28.8 mg/dL (range 12-60). Thirty-two patients (97.0%) showed neuroglycopenic symptoms, with consciousness disturbance (30.3%) and seizure (24.2%), sweating (18.2%), confusion (15.2%), asthenia (12.1%) being the most common symptoms. Fifteen patients (44.1%) had elevated serum insulin levels, with a median of 31.8 μU/mL (range 3-115.3). C-peptide increased in 13 patients (38.2%), with a median of 7.7 ng/mL (range 2.2-20). Complete recovery from symptoms occurred in 88.2% of patients without sequelae. The duration of hypoglycemia symptoms was 8 hours to 47 days after the intervention. Interventions included discontinuation of TMP-SMX, intravenous glucose, glucagon, and octreotide.

CONCLUSION

Hypoglycemia is a rare and serious adverse effect of TMP-SMX. Physicians should be aware of this potential adverse effect, especially in patients with renal insufficiency, increased drug doses, and malnutrition.