Ketoacidosis is one of the most extreme complications of diabetes mellitus that can be experienced. Unfortunately, most cases of ketoacidosis are in patients that were not previously known to be diabetic so the owner (and pet) must deal with two serious diagnoses: one acutely life-threatening and expensive and the other requiring ongoing commitment and daily treatment.

The diabetic patient has an insulin deficiency. To recap, there is a huge amount of glucose in the bloodstream but without insulin, none of it can get inside the cells that need it. It just circulates around uselessly. The tissues, some of which require glucose as their only food, are starving. Add to this some sort of second stressful condition such as infection or pancreatitis, and the tissue demand for food/fuel increases. The tissues, including the brain, become especially desperate and the body begins to frantically break down fat in order to liberate the small amount of carbohydrate (which can convert to glucose) contained therein.

Fat is able to convert to a biochemical called a ketone body. Ketone bodies can be used as an alternative fuel source by tissues that require glucose (brain, red blood cells, etc.). This will save the day in the short term but the problem is that ketone bodies do not “burn clean.” When ketone bodies are burned, pH and electrolyte imbalances ensue. These imbalances create dehydration, which in turn creates more pH and electrolyte imbalances. A metabolic disaster results if this state of glucose desperation persists.

Most patients in diabetic ketoacidosis are lethargic, depressed, and will not eat. They are dehydrated and frequently nauseated. Blood glucoses are extremely high and ketones can be detected in the urine. The goal is to gradually correct all the imbalances, get the patient out of the extreme fat-burning state, and establish some sort of initial regulation of the diabetes. 

Prognosis is generally fair as long as the complicating disease (the disease that is happening on top of the diabetes mellitus) can be resolved. That said, round-the-clock monitoring of electrolytes and blood sugars is needed to safely guide the patient through the crisis, and this kind of care has significant expense. Ketoacidosis involves potential disasters in potassium, phosphorus, pH, blood sugar, and sodium. All of these parameters must be controlled. The goal is to convert the complicated diabetic patient into an uncomplicated diabetic patient, but the patient will still be diabetic at the end of treatment.

What to Expect in the Hospital

The sooner the crisis is recognized, the faster treatment can be started. Because electrolytes can change moment by moment, blood testing is necessary throughout the day to keep track and keep the imbalances corrected. A facility that offers 24-hour care is ideal. Aside from the monitoring required to manage the ketoacidosis, testing to determine the precipitating stress is necessary as well.

In dogs, the most common precipitating/concurrent conditions are pancreatitis, urinary tract infection, and Cushing’s disease. In cats, precipitating/concurrent conditions include hepatic lipidosis, kidney infection, pancreatitis, and cholangiohepatitis.

Intravenous Fluids

Fluid therapy is the key to treatment. The patient is invariably dehydrated from the high circulating blood sugar levels, which cause excess fluid loss in urine, as well as from vomiting or diarrhea, which are common in ketoacidosis. Aside from simply providing fluids, the IV fluid provides a vehicle by which other metabolic derangements can be repaired.

Insulin

Blood sugar must be controlled if treatment is to be successful but to prevent brain damage, blood sugar levels must be dropped slowly. To achieve this, “regular insulin” (typically Humulin R®) is used, given either as multiple intramuscular injections or as a continuous drip. This type of insulin is short-acting and wears off quickly, which allows it to provide small adjustments. It is not until the patient is eating and nausea has been controlled that maintenance insulins can be started.

Potassium

Patients in ketoacidosis are greatly depleted in potassium. While insulin is needed to control blood sugar, insulin makes the problem worse by driving potassium into the body’s cells and out of the bloodstream. Typically, high amounts of potassium must be supplemented in the intravenous fluid solution.

Phosphorus

Low levels of phosphorus also accompany diabetic ketoacidosis and if levels drop too low, the patient’s red blood cells will begin to burst and be unable to maintain integrity. Phosphorus is also supplemented through the intravenous fluid solution.

Blood pH

The term ketoacidosis implies that the blood pH is overly acidic. If the situation is severe enough, sodium bicarbonate must be added to the intravenous therapy.

All these aspects require regular monitoring, which means lab work perhaps four times daily or more. Patients in diabetic ketoacidosis require close monitoring and intensive care.

When urine dipsticks no longer test positive for ketones and the patient is eating well and in good spirits, he or she is able to go home and be managed as a regular diabetic. Diet, monitoring, insulin etc. will be on-going concerns. Ideally, Ketostix, obtainable from any drug store, will be used at home to monitor for ketones to head off problems before they become extreme in the future.

It turns out each type has a different potential for toxicity. In order to understand which types of chocolates are more toxic, we will need to review how chocolate is made.

Cocao trees, which require a tropical climate, are farmed in orchards like any other fruit-bearing tree. The fruit of the cacao tree, called a cacao pod, is sweet and attracts monkeys or other wildlife who eat the fruit but not the bitter seeds. The seeds are discarded in the natural setting, allowing new trees to grow. Outside of the farm situation, the seeds cannot be released from the fruit unless some type of animal breaks the fruit open. Ironically, it is the bitter seeds, packed with theobromine and caffeine, which are used to make chocolate.

The pods grow directly off the trunk of the cacao tree and must be harvested by hand so as not to damage the tree. The pods are split, and the seeds are scooped out and left to ferment under banana leaves for about a week. This process turns the cocoa seeds into the rich brown color with which we are familiar and creates the chocolate flavor we crave.

The seeds are then dried out for another week, packed in sacks, and shipped to chocolate manufacturers. The seeds must be roasted, ground, pressed to remove the seed oil (this oil is called cocoa butter, which is used in sunscreens, white chocolate, and cosmetics, among other things), and finally tempered to create the exact consistency.

• Chocolate liquor is the liquid that results from grinding the hulled cacao beans.
• Cocoa butter is the fat that is extracted from chocolate liquor. It is combined with sugar and flavoring to create white chocolate. White chocolate is not directly toxic as it has no chocolate liquor, but its rich fat content can be a problem, as discussed below.
• Cocoa powder is the solid that remains after the cocoa butter is removed from the chocolate liquor. The powder can be treated with alkali in a process called Dutching, or it can be left alone. Note the low-fat nature of cocoa powder, hence its use in low-fat baking.
• Unsweetened (baking) chocolate is basically straight chocolate liquor containing 50% to 60% cocoa butter.
• Dark chocolate (also known as semisweet chocolate) is chocolate that is 35% chocolate liquor (the rest being sugar, vanilla, or lecithin).
• Milk chocolate is chocolate that is at least 10% chocolate liquor, the rest being milk solids, vanilla, or lecithin.
• Chocolate liquor is the one with all the problem biochemicals. The more chocolate liquor is in the end product (i.e., how dark the chocolate is), the more toxic it is.                                                                                                                                                                                                                      Pancreatitis

Sometimes we eat chocolate plain, as in candy. Sometimes we eat it baked into cakes, mixed into ice cream, etc. Sometimes we share these treats with pets, and sometimes, our pets share these treats without our permission. As far as pets are concerned, the first potential problem with these sweets is the fat. A sudden high-fat meal (such as demolishing a bag of chocolate bars left accessible at Halloween time) can create a lethal metabolic disease in dogs called pancreatitis.  Vomiting, diarrhea, and abdominal pain are just the beginning of this disaster. Remember, in the case of pancreatitis, it is the fat that causes the problem more than the chocolate itself.

The fat and sugar in the chocolate can create an unpleasant but temporary upset stomach. This is what happens in most chocolate ingestion cases.

Theobromine and Caffeine

Theobromine causes:

• Vomiting 
• Diarrhea 
• Hyperactivity 
• Tremors 
• Seizures 
• Racing heart rhythm progressing to abnormal rhythms 
• Death in severe cases

Toxic doses of theobromine are 9 mg per pound of the dog’s weight for mild signs and up to 18 mg per pound for severe signs. Milk chocolate contains 44 mg per ounce of theobromine, semisweet chocolate contains 150 mg per ounce, and baking chocolate contains 390 mg per ounce. White chocolate has virtually no theobromine and is only a problem because of its fat content. These calculations seem complex, and they certainly can be. What it boils down to is that your veterinarian will need to know the type of chocolate and how many ounces were most likely consumed. If it is not clear how much chocolate was actually consumed, the largest possible amount should be determined based on how much candy, cake, etc., is missing.

It takes nearly four days for the effects of chocolate to work its way out of a dog’s system. If the chocolate was only just eaten, it is possible to induce vomiting; otherwise, hospitalization and support are needed. It is common for clinics to receive phone calls about pets who were found to have consumed a chocolate product, and the owner wishes to know if the amount was toxic. In order to answer such questions, it is necessary to know the pet’s weight, the type of chocolate, and the amount of chocolate. Chocolate calculators are available at most veterinary practices, and it can be determined relatively quickly if the pet should be made to vomit immediately. 

Treatment

As mentioned, the first step is to remove as much chocolate from the body as possible by inducing vomiting or using adsorbents such as activated charcoal to bind the chocolate and keep it from being absorbed by the GI tract.  For many patients, removing undigested chocolate converts the toxicity from neurologic poisoning to just an upset stomach that is easily managed. If too much caffeine/theobromine has been absorbed, the treatment is support: sedation for the tremors and intravenous medications for any cardiac arrhythmias. Support is needed until the toxins have been processed and removed from the body so expect severe cases to need intravenous fluid support and hospitalization for a few days.

An ounce of prevention is worth a pound of cure. Keep chocolate treats where your pet cannot reach them.