A 9-year-old spayed female, 5.2-kg, Maltese presented to a satellite emergency clinic after ingesting ~40 Dasuquin chews. Upon returning home, the owner found 10 piles of vomitus along with a Dasuquin bag on the floor. The vomitus consisted of undigested food and Dasuquin chews. The patient presented to the emergency hospital having grand mal seizures. An intravenous catheter was placed, and a dose of Diazepam was administered (0.5 mg/kg, intravenously [IV]). Maropitant (Cerenia 1 mg/kg, IV) was administered due to ongoing vomiting. Vital parameters showed a rectal temperature of 37.5°C (99.6°F), a heart rate of 140 beats per minute with poor pulses, and a respiratory rate of 40 respirations per minute. The patient's mucous membrane color was pale and dry, with a prolonged capillary refill time (>2 s). On examination, the patient's level of consciousness was obtunded with a grade I/VI heart murmur and had significant ptyalism. Point of care bloodwork showed a PCV of 60% (reference interval, [RI]: 36–46%), total plasma protein of 100.6 g/L (10.6 g/dL; [RI: 65–80 g/L; 6.5.−8.0 g/dL]), hyperglycemia of 21.6 mmol/L (388 mg/dL; [RI: 4.1–7.9 mmol/L; 74–143 mg/dL]), and lactate of 2.7 mmol/L (RI: 0–2 mmol/L). Full blood work was performed that revealed a hematocrit of 75.3%, (RI: 38.3–56.5%), azotemia with a BUN of 12.3 mmol/L (34.5mg/dL; [RI: 5.3–11.4 mmol/L; 15–32 mg/dL]), creatinine of 123 umol/L (1.4 mg/dL; [RI: 35-123 umol/L; 0.4–1.4 mg/dL]), blood glucose (BG) of >33.3 mmol/L (>600 mg/dL, [RI: 4.1–7.9 mmol/L; 74–143 mg/dL]), sodium of 160 mmol/L (RI: 140–151 mmol/L), hyperchloremia of 130 mmol/L (RI: 106–127 mmol/L), hyperkalemia of 8.7 mmol/L (RI: 3.5–5.0 mmol/L), and hyperphosphatemia at 2.5 mmol/L (7.9 mg/dL; [RI: 0..6–1.6 mmol/L; 1.9–5.0 mg/dL]). Hepatobiliary enzymes showed a normal alanine transaminase, elevations in aspartate transaminase of 85 U/L (RI: 16–55 U/L), alkaline phosphatase of 185 U/L (RI: 5–160 U/L), gamma-glutamyl transferase of 55 U/L (RI: 5–16 U/L), and elevated total bilirubin at 42.75 umol/L (2.5 mg/dL; [RI: 1.7–13.7 umol/L; 0.1-0.8 mg/dL]). Acid–base status was not obtained at that time. The patient was hypotensive with systolic blood pressure (SBP) via Doppler of 44 mm Hg. Two 20 mL/kg IV boluses of Plasmalyte (Plyte) were administered with minimal improvement in SBP (56, 50 mm Hg). The patient had two additional seizures, so diazepam (0.5 mg/kg IV) was administered again. A single dose of regular insulin (Humulin-R 0.2 U, IV) was given for persistent hyperglycemia. A recheck of the BG reading was 29 mmol/L (528 mg/dL; [RI: 4.1-7.9 mmol/L; 74–143 mg/dL]), 2 h after regular insulin administration. A loading dose of 140 mg/kg of N-Acetylcysteine was given IV. On repeat assessment, the patient was hypothermic (31.4 C [93.5° F]) and remained hypotensive (SBP 70 mm Hg). Due to the critical nature, patient care was transferred to the critical care service at the main facility. On presentation to the main facility (3 h post-treatment initiation), the patient was obtunded with delayed pupillary light and palpebral reflexes and absent menace and gag reflexes. There was slight tachypnea with normal lung sounds. Venous blood gas (see ) revealed worsening azotemia with a creatinine of 152 umol/L (1.73 mg/dL; [RI: 35–123 umol/L; 0.4–1.4 mg/dL]), persistent hyperglycemia at 36 mmol/L (654 mg/dL; [RI: 4.1–7.9 mmol/L; 74–143 mg/dL]), ongoing hypernatremia (161 mmol/L; [RI: 140–151 mmol/L]), hyperchloremia (>140 mmol/L; [RI: 106–127 mmol/L]), hyperkalemia (5.3 mol; [RI: 3.5–5.0 mmol/L]), and severe acidemia (pH 6.885; [RI: 7.24–7.4]). On abdominal-focused assessment, the stomach was severely distended with fluid, so a nasogastric tube (NG tube) was placed. Approximately 60 ml of viscous fluid was removed. Oxygen saturation was normal at 98%, and thoracic radiographs were normal. Aspiration pneumonia with radiographic lag could not be ruled out. The patient was still hypotensive, so two boluses of 20 ml/kg of Plyte were given in addition to a 10-ml/kg bolus of dextrose in water (D5W). A continuous rate of fluids was started at 2.5 times the resting energy requirement (RER) with two-thirds of the total volume comprising D5W and one-third Plyte. N-Acetylcysteine was continued at a maintenance dose of 70 mg/kg IV every 6 h. Blood pressures were monitored hourly, and venous blood gases and blood sugar were monitored every 2–4 h. Regular insulin (Humulin R, 1 unit IV) was scheduled to be given if the patient remained hyperglycemic (BG >250 mg/dL). A jugular catheter (5 French, 13 cm, triple lumen MILA) was placed for ease of blood sampling and to facilitate the administration of multiple fluids and medications. The patient had the area of her neck clipped and aseptically prepared. The patient was measured for the final insertion point of the jugular catheter at the 3–4 intercostal space. A large bore over-the-needle catheter was introduced into the jugular vein, with the tip pointing in the direction of the heart. The guidewire was then inserted into this catheter to the pre-measured length. The needle catheter was removed, and a plastic dilator was used to dilate the vessel. The dilator was then removed, and the catheter was then inserted over the guidewire to the pre-measured length. The catheter was then sutured into place, and a bandage was placed over the catheter. A 6 French urinary catheter was placed to monitor urine output every 4 h. The patient had the peri vulvar area clipped and aseptically prepared. A stylet was lubricated with sterile lubrication and introduced into the catheter. The tip of the catheter was lubricated with sterile lubrication as well. The urethral papilla was palpated, and the catheter was introduced into the urethra and the bladder. The foley was inflated with the designated amount of sterile saline, and a collection system was attached. NG tube aspiration was performed every 4 h. Another venous blood gas was performed 2 h later (hour 5), which revealed worsening hypernatremia (166 mmol/L; [RI: 140–151 mmol/L]), hyperglycemia (33 mmol/L [608 mg/dL]; [RI: 4.1–7.9 mmol/L; 74–143 mg/dL]), elevated creatinine (153 umol/L [1.79 mg/dL]; [RI: 35–123 umol/L; 0.4–1.4 mg/dL]), and acidemia (pH 6.904; [RI: 7.24–7.4]). Given the worsening hypernatremia, the IV fluids were changed to D5W only and continued at 2.5 RER. The patient was also administered a 10 ml/kg water retention enema. Hypotension persisted, so a broad-spectrum bactericidal antibiotic that acts by inhibiting cell wall synthesis (Unasyn 30 m/kg, IV) was added for possible gastrointestinal bacterial translocation or undetected aspiration pneumonia. A norepinephrine continuous rate infusion was started at 1 ug/kg/min. Focal seizures returned, so another dose of diazepam was administered (0.5 mg/kg IV). Venous blood gas showed (hour 9) worsening hypernatremia (170 mmol/L; [RI: 140–151 mmol/L]), hyperglycemia (29 mmol/L; [522 mg/dL]; [RI: 4.1–7.9 mmol/L; 74–143 mg/dL]), and acidemia (pH 6.975; [RI: 7.24–7.4]). Humulin R was given (1 unit, IV). The free water deficit () was calculated, and the volume was given over 12 h utilizing D5W. Plyte was restarted at maintenance RER. The base deficit () was calculated, and a dose of sodium bicarbonate was given at 1/3 of the calculated deficit (12 mEq, IV). The dose of Humulin R was increased (2 units, IV). After 2 h of the sodium bicarbonate administration, another venous blood gas was performed (hour 11), which revealed a small improvement in the hypernatremia (166 mmol/L; [RI: 140–151 mmol/L]), ongoing hyperglycemia (23 mmol/L; [416 mg/dL]; [RI: 4.1–7.9 mmol/L; 74–143 mg/dL]), improved acidemia (pH 7.096; [RI: 7.24–7.4]), and new hypokalemia (2.3mmol/L; [RI: 3.5–5.0 mmol/L]). Plyte was supplemented with potassium chloride at 0.07 mEq KCL/kg/hr. A second dose of sodium bicarbonate (12 mEq, IV) was given for persistent acidemia. Venous blood gas was performed (hour 13), which revealed an improvement in the hypernatremia (160 mmol/L; [RI: 140–151 mmol/L]) and acidemia (pH 7.202; [RI: 7.24–7.4]). The BG was normal. Fluids were unchanged with D5W and continued to correct the free water deficit and Plyte at RER with potassium chloride supplementation. The norepinephrine infusion was discontinued as the patient had remained normotensive for the preceding 4 h. By the next venous blood gas (hour 17), the sodium was normalized (144 mmol/L; [RI: 140–151 mmol/L]), but the acidemia worsened slightly (pH 7.177; [RI: 7.24–7.4]). Hyperkalemia returned (7.2 mmol/L; [RI: 3.5–5.0 mmol/L]) as did the hyperglycemia (19.7 mmol/L; [354 mg/dL]; [RI: 4.1–7.9 mmol/L; 74–143 mg/dL]). Humulin R was given at a lower dose (1 unit IV), and the D5W and potassium supplementation were discontinued. Plyte was continued at three times the RER due to high rates of residual gastric volume (average 4.2 ml/kg/h) and polyuria (average 7.8 ml/kg/h). By day 2 of hospitalization (24 h post-treatment initiation), the patient was persistently normoglycemic and normotensive. Mentation was normal with normal cranial nerve and intact vision. The patient started eating well. Venous blood gas (hour 24) revealed normal sodium, potassium, BG, and only mild acidemia (pH 7.309; [RI: 7.24–7.4]). Plyte was slowly tapered to RER. The residual gastric volume started to decrease, so the NG tube was removed. Urine output decreased as IV fluids were decreased, so the urinary catheter was removed. Regular insulin administration was discontinued. A recheck of venous blood gas in the afternoon revealed hypokalemia (2.8 mmol/L; [RI: 3.5–5.0 mmol/L]) as the only abnormality. Potassium supplementation was added to IV fluids (0.1 mEq KCL/kg/hr). The patient continued to eat and drink with no further seizures. On day 3 of hospitalization, a chemistry panel revealed elevations in aspartate transaminase (191 U/L; [RI: 16–35 U/L]), alanine transaminase (138 U/L; [RI: 14–87 U/L]), and alkaline phosphatase (244 U/L; [RI: 20–157 U/L]). Other biochemical abnormalities included hypoalbuminemia (24 g/L [2.4 g/dL]; [RI: 23–39 g/dL; 2.3–3.9 mg/dL]), elevated pancreatic serum lipase (380 U/L; [RI: 24–140 U/L]), and elevated creatine phosphokinase (15,796 IU/L; [RI: 59–895 U/L]). The patient was discharged on a liver protectant. A recheck of bloodwork on day 7 post-discharge was normal. No medications were continued. There was no further follow-up.