Fluid therapy

in health, approximately 60% of an adult animals body weight is water

estimates of total body water in adult dogs that are neither very thin nor obese are 534 to 660 mL/kg

total body water of adult cats also was determined to be approximately 60%
neonatal dogs and cats have higher total body water content (80% of body weight) than adults (60% of
body weight), and an age related decrease in total body water has been described in puppies and kittens
during the first 6 months of life.
because fat has a lower water content than lean tissue, fluid needs should be estimated on the basis of
lean body mass to avoid overhydration, especially in patients with cardiac or renal insufficiency or in
those with hypoproteinemia

Fluid distribution within body

The composition of intracellular fluid is very different from extracellular fluid

Extracellular fluid
mEq/l
Na+
K+
Ca2+
ClHCO3Mg2+

Intracellular fluid
mEq/l

Physical examination in dehydrated patient

the physical findings associated with fluid losses of 5% to15% of body weight
no clinically detectable changes (5% dehydration) to signs of hypovolemic shock and impending death
(15% dehydration)
the clinician may estimate the hydration deficit by evaluating:
skin turgor or pliability

the moistness of the mucous membranes

the position of the eyes in their orbits
heart rate
character of peripheral pulses
capillary refill time

Physical examination in dehydrated patient

semidry oral mucous membranes, normal skin turgor, and eyes maintaining normal moisture indicate
4%5% dehydration

dry oral mucous membranes, mild loss of skin turgor, and eyes still moist indicate 6%7% dehydration.

dry mucous membranes, considerable loss of skin turgor, retracted eyes, acute weight loss, and weak
rapid pulses indicate 8%10% dehydration
very dry oral mucous membranes, complete loss of skin turgor, severe retraction of the eyes, dull eyes,
possible alteration of consciousness, acute weight loss, and thready, weak pulses indicate 12%
dehydration.

Physical examination in dehydrated patient

the fluid deficit in a given patient is difficult to determine with accuracy because of the subjectivity of skin
turgor evaluation

detection of dehydration by skin turgor is dependent on:

the animals skin turgor before dehydration developed
the position of the animal (e.g., standing, recumbent) when the skin is checked
the site used for evaluation
the amount of subcutaneous fat

when evaluated by skin turgor, obese animals may appear well hydrated owing to excessive
subcutaneous fat despite being dehydrated.

emaciated animals and older animals may appear more dehydrated than they actually are because of lack of
subcutaneous fat and elastin
a false impression of dehydration also may occur with persistent panting, which may dry the oral mucous
membranes.

Physical examination in dehydrated patient

a large, urine-filled bladder in a severely dehydrated patient indicates failure of the normal renal
concentrating mechanism.
body weight recorded on a serial basis traditionally has been thought to be the best indicator of
hydration status, especially when fluid loss has been acute and previous body weight has been recorded

loss of 1 kg of body weight indicates a fluid deficit of 1 L

unfortunately, previous body weight is often unknown in animals presented for treatment. However,
records from previous routine hospital visits may provide this information.

Laboratory findings

the hematocrit or packed cell

volume (PCV), total plasma
protein concentration (TPP), and
urine specific gravity (USG) are
simple laboratory tests that can aid
in the evaluation of hydration

Laboratory findings

the USG before fluid therapy is helpful in the preliminary evaluation of renal function
USG should be high (>1.045) in a dehydrated dog or cat if renal function is normal

this may not be true if other disorders affecting renal concentrating ability, such as medullary washout of
solute, are present
previous administration of corticosteroids or furosemide can decrease urinary concentrating ability
after fluid therapy has been initiated, USG falls into the isosthenuric range if rehydration has been achieved

Types of fluid
a fluid is said to be balanced if its composition resembles that of extracellular fluid (ECF; e.g., lactated
Ringers solution, and unbalanced if it does not (e.g., normal saline)
crystalloids or colloids
crystalloids are solutions containing electrolyte and nonelectrolyte solutes capable of entering all body
fluid compartments (e.g., 5% dextrose, 0.9% saline, lactated Ringers solution)

crystalloids exert their effects primarily on the interstitial and intracellular compartments
administering 5% dextrose is equivalent to giving water because the glucose is oxidized to CO2 and
water. In fact, the main reason for giving 5% dextrose is to correct a pure water deficit. Except in very
small animals, administration of 5% dextrose cannot be relied on to maintain daily caloric needs
because 5% dextrose contains only 200 kcal/L

Types of fluid
crystalloid solutions with preservatives must be avoided in cats
benzoic acid derivatives (e.g., benzyl alcohol) have been added to some solutions for their antimicrobial
effect
clinical signs in cats receiving fluids with such preservatives have included behavioral changes,
hypersalivation, ataxia, muscle fasciculations, seizures, dilated nonresponsive pupils, coma, and
death
young cats may be at increased risk for these complications.

Types of fluid
colloids are large-molecular-weight substances that are restricted to the plasma compartment in
patients with an uncompromised intact endothelium and include plasma, dextrans and
hydroxyethyl starch (hetastarch)

colloids exert their primary effect on the intravascular compartment

some types of colloids may be used in patients with shock and in those with severe
hypoalbuminemia (i.e., albumin <1.5 g/dL)
Dextran 70 is a polymer of glucose that has an average molecular weight of 70,000. Its use in
humans has been associated with coagulopathies

Hetastarch has an average molecular weight of 480,000. In humans, coagulopathies also have
been associated with the use of hetastarch but typically only when standard dosage
recommendations have been exceeded

the main advantages of colloids are that more of the administered solution remains in the plasma
compartment and there generally is thought to be less risk of edema in patients with an intact
endothelium.

Routes of administration
the intravenous route is preferred when the patient is very ill, when there has been severe fluid loss, or when the
fluid loss has been acute
the intravenous route provides rapid dispersion of water and electrolytes and allows precise dosage
a large volume can be given rapidly, and hypertonic fluids can be given safely via a large vein
the veins available for vascular access include the jugular, cephalic, lateral saphenous, and femoral veins.
there are advantages and disadvantages of each, but the jugular vein is most useful because it allows delivery of
large volumes, administration of hypertonic or potentially irritating solutions, measurement of CVP, and
repeated venous blood sampling.
the cephalic vein also is commonly used, but fluid delivery can be hindered by flexion of the elbow, and extremely
hypertonic or irritating solutions should not be used

the catheter-skin interface should be monitored routinely to detect complications.

Routes of administration
the subcutaneous route is convenient for maintenance fluid therapy in small dogs and cats

the subcutaneous space in dogs and cats can accommodate relatively large volumes of fluid, and potassium
can be used in concentrations up to 30 to 35 mEq/L without irritation
fluid is administered under the skin along the back from the area of the scapulae to the lumbar region
volume overload is unlikely to occur when fluids are administered subcutaneously in patients with no
underlying cardiac insufficienc
the subcutaneous route is not adequate for patients with acute and severe losses (e.g., shock) and is not
recommended for extremely dehydrated or hypothermic animals because peripheral
irritating or hypertonic solutions must not be used subcutaneously; only isotonic fluids are recommended
the subcutaneous administration of 5% dextrose in water should be avoided because equilibration of ECF with a
pool of electrolyte-free solution may lead to temporary aggravation of electrolyte imbalance.

Routes of administration

the oral route is most physiologic, and fluids with a wide variety of compositions may be given

fluid can be administered rapidly with minimal adverse effects, and caloric needs can be met

this route should not be used in the presence of gastrointestinal dysfunction (e.g., vomiting, diarrhea)
the oral route also is inadequate in animals that have had acute or extensive fluid losses because
dispersion and use of the administered fluid and electrolytes are not sufficiently rapid

in anorexic animals without vomiting or diarrhea, fluid can be administered orally using a number of
different techniques (e.g., nasogastric tube, esophagostomy tube, gastrostomy tube).

Routes of administration

the intraosseous, or intramedullary, route is useful in very young or small animals in which venous
access is difficult
the bone marrow does not collapse when the patient is hypovolemic, and access to the marrow is simple
sites that can be used for intraosseous administration of fluid include the tibial tuberosity, trochanteric
fossa of the femur, wing of the ilium, and greater tubercle of the humerus
the periosteum should be anesthetized by infiltration with 1% lidocaine solution to avoid pain during
needle placement
the potential risks include osteomyelitis and pain on administration of fluid.

Fluid dosage

the rate of fluid administration is dictated by the magnitude and rapidity of the fluid loss
the shock dosage of synthetic colloids is 20 mL/kg for dogs and 10 to 15 mL/kg for cats
the shock dosage of isotonic crystalloids is 80 to 90 mL/kg for dogs and 40 to 60 mL/kg for cats
in experimental studies, crystalloid fluids administered at 90 mL/kg/hr did not cause pulmonary edema in normal
dogs and cats

it should be noted that intravenous crystalloids should be used judiciously in cats because the lung is the shock
organ in the cat and fluid overload and pulmonary edema can rapidly occur. An initial bolus of 15 to 20 ml/kg
every 15 to 20 minutes up to 60 ml/kg (distributive shock) is often effective at providing fluid resuscitation while
avoiding fluid overload and pulmonary edema.

Fluid dosage

anesthetized cats receiving lactated Ringers solution at a rate of 225 mL/kg for 1 hour developed:

serous nasal discharge

chemosis (oedema of the conjunctiva)

ascites, diarrhea

fluid exudation from catheter sites

at necropsy, these cats had ascites, pancreatic edema, and accumulation of free fluid in the trachea.

Fluid dosage

maintenance fluid therapy is around 40-60 ml/kg/day

approximately two thirds of the maintenance requirement represents sensible (i.e., easy to measure) losses
of fluid (urine output), and one third represents insensible (i.e., difficult to measure) losses (primarily fecal
and respiratory water loss)
thus daily maintenance for a 10-kg dog may be 600 mL, with 400 mL representing sensible loss and 200
mL representing insensible loss.

Monitoring fluid therapy

a complete physical examination, including evaluation of skin turgor and careful thoracic auscultation, should
be performed once or twice daily for animals receiving fluid therapy
when assessing response to fluid therapy in animals with pain, an opioid analgesic (preferably hydromorphone or
fentanyl) should be administered to control pain

hematocrit, TPP, and body weight should be monitored.

serial body weight has been considered one of the most important variables to follow, and animals receiving
continuous fluid therapy should be weighed once or twice daily using the same scale

a gain or loss of 1 kg can be considered an excess or deficit of 1 L of fluid because lean body mass is not quickly
gained or lost
a dehydrated patient should gain weight as rehydration is achieved, and afterward weight should remain relatively
constant
however, weight may increase without restoration of effective circulating volume in patients with severe thirdspace losses.

Monitoring fluid therapy

Urine output
the clinician should observe the animals urine output carefully after fluid therapy has begun
oliguria should be strongly suspected in patients with acute renal failure, especially those with possible
ethylene glycol ingestion
normal urine output is 1 to 2 mL/ kg/hr. As the patient becomes rehydrated, physiologic oliguria should
resolve, and urine output should increase while urine specific gravity (USG) decreases
if oliguria that was present at admission persists after the hydration deficit has been replaced, it is
prudent to divide daily fluid therapy into six 4-hour intervals if the status of renal function is uncertain.
if oliguria does not respond to mild volume expansion, administration of increased volumes of fluid
may result in pulmonary edema.

Monitoring fluid therapy

Central venous pressure (CVP)

measurement of CVP with a jugular catheter positioned at the level of the intrathoracic vena cavae
normal CVP is 0 to 3 cm H2O

CVP increases from below normal into the normal range when fluids are administered to a dehydrated
animal
a progressive increase in CVP above normal during fluid therapy is an indication to decrease the rate of
fluid administration or to stop fluid therapy temporarily
a sudden and sustained increase in CVP may indicate failure of the cardiovascular system to handle the
fluid load effectively and could result in pulmonary edema caused by left-sided heart failure.

Monitoring fluid therapy

Lactate
the blood lactate concentration may be used as an indicator of perfusion to monitor resuscitation
lactate measurements can be performed on arterial or venous sample
normal blood lactate concentrations are less than 2.0 mmol/L in dogs, with 3 to 5 mmol/L
representing a mild increase, 5 to 8 mmol/L a moderate increase, and more than 8 mmol/L a severe
increase

normal blood lactate concentrations are less than 1.46 mmol/L in cats

obtaining an initial lactate measurement in all severely ill patients can serve as a useful method of
evaluating severity of illness or injury. The most common cause of hyperlactatemia is hypoperfusion
and tissue hypoxia.