WHAT IS FLUID THERAPY?

Fluid Therapy is the administration of

fluids to a patient as a treatment or
preventative measure. It can be
administered via an intravenous,
intraperitoneal, intraosseous,
subcutaneous and oral routes.
60% of total bodyweight is accounted
for by the total body water. This can
further be divided into intracellular or
extracellular as shown below.
 Total body water (60% of body weight)

 20% extracellular fluid

plasma volume 5%
interstitial fluid 15%

 40% intracellular fluid

 Fluid therapy is indicated either
 when there is a loss of fluid to any part of these
compartments or there is a risk of loss of fluid.
 The severity of the fluid loss, and the
compartment from which it has been lost,
 influence the choice of fluid and the speed at
which it needs to be administered.
 If fluid therapy is performed as a treatment
then it is necessary to diagnose and treat the
underlying condition.
Indications:

1. Hypotension
2. Dehydration
3. Hypovolemia
4. Electrolyte, metabolic and acid base
disorders
5. Decreased oxygen delivery
6. Geriatric patients at risk of organ failure
In order to formulate an appropriate fluid Tx
plan, it is important to understand the goals of
therapy:
 Hypovolemia vs. Dehydration
Hypovolemia- is defined as a loss of fluid from
the intravascular space. Dog 70-80 ml/kg; cat
60-65 ml/kg. Assessed by evaluation of heart
rate, pulse rate & quality, mucous membrane
color, perfusion of distal extremities & capillary
refill time. Lab. Changes include: increased PCV
or TPP, metabolic asidosis & hyperlactataemia.
 Dehydration- is defined as fluid loss from the
interstitial & intracellular space. Assessed by
animal’s mentation, skin elasticity, mucous
membrane moisture, & orbital position.

 Fluid therapy for dehydration

 Crystalloid fluid to be administered w/in 6-24
hrs. period depending on the extent of fluid
loss.
CLINICAL % DEHYDRATION
SIGNS slight mild moderate severe
5 7 9 11

Gum Moisture Slightly dry Dry Dry No moisture

Skin tent Slight Mild Moderate Significant

Eye Normal Slightly Sunken eyes Sunken eyes

prominence decrease
Mild to Unable to
Pulse quality Normal Slightly moderately palpate distal
decrease decrease pulses, poor
femoral pulse

PCV/TS Normal to Mildly increase Moderately Severely

slightly increase increase increase

Blood pressure Normal Normal to Moderately Very low or

decrease decrease unable to
measure

Urine output Normal Decrease Oliguria Anuria

 Fluid therapy for hypovolemia
It is life threatening. The goal of immediate fluid
therapy is to return the heart rate/pulse quality
to normal & to obtain a normal blood pressure.
Recommended type of fluid: crystalloid &
colloid.
Goals of fluid therapy for
Hypovolemia
DOG CAT

Heart Rate >60 bpm <140 bpm >100 bpm <200 bpm
Mucous membrane color Pink Pink
Capillary refill time (CRT) < 2 seconds <2 seconds

Pulse pressure Palpable metatarsal Palpable metatarsal

pulse pulse
Blood pressure >100/80 mmHg >100/80 mmHg

Distal extremities Warm Warm

PCV Normal Normal
TPP Normal Normal
Lactate <2 mmol/L <1.4 mmol/L
Urine output >0.5-1ml/kg/hr >0.5-1 ml/kg/hr
Fluid rates & types:

 Crystalloids:
 Isotonic fluids- LRS, 0.9% NaCl, Plasmalyte-
148, Normosol R. Designed to rapidly fill the
intravascular space within 60 mins.
 Hyp0tonic (low sodium)- should never be
used for shock rescuscitation as the fluid
redistribute too quickly out of the vascular
space.
 Hypertonic saline:
 Causes rapid increase in intravascular volume
due to its osmotic effect w/in the vascular
space causing fluid to shift out of the
interstitial compartment. It has a short
duration of effect 15-30 mins.
 7% Na Cl can be administered at 3-5ml/kg in
dogs, or 1-3 ml/kg in cat.
 Used in conjunction w/ colloids.
 Contraindicated in dehydrated patients.
 Colloids: (hetastarch, whole blood)
 Are high molecular weight fluids that increase
vascular oncotic pressure & help to retain
fluid within the intravascular space.
 A bolus of 10-20 ml/kg in dogs and 5-15 ml/kg
in cats over 20-60 mins.
 Crystalloid fluids rates can usually be halved if
there is concurrent admin. of colloid.
 Definitions:
 Osmosis is the net movement of water across a semi
permeable membrane. The movement is caused by
a concentration gradient due to different solute
concentrations on each side of the membrane.
 Osmotic Pressure is the pressure caused by the
solutes within the solution. The solute
concentration prevents water movement across the
membrane.
 Tonicity is the term used to compare the osmotic
pressure of different solutions
 A hypotonic solution is one that has an osmotic
pressure lower than plasma.
 An isotonic solution is one that has an osmotic
pressure the same as plasma.
 A hypertonic solution is one that has an osmotic
 Hypovolaemia is a reduction in normal blood
volume which can be caused by:
 Excessive sweating
 Water deprivation
 Vomiting and diarrhoea
 Haemorrhage
 Pathological dilatation of capacity of the circulatory
system, and therefore a relative reduction in
circulating blood.
 Hypervolaemia' is an increase in blood volume,
which can be caused by congestive heart
failure.
Types of Fluids

 Crystalloids are able to enter all body

compartments.
 Colloids are restricted to the plasma
compartment.
 If there is an electrolyte imbalance present
then it may be necessary to add the
appropriate electrolyte solution.
Fluid Rate Calculations

 When calculating the fluid requirements of a

patient, there are 3 elements to consider -
1. Replacement
2. Maintenance
3. Ongoing Losses
 Replacements are calculated based on the
level of dehydration. Dehydration is based
upon clinical assessment of each individual
patient. Most commonly, skin tent is used for
assessment. To calculate the amount required
for replacement within a 24 hour period, the
percentage dehydration is used in the
following calculation.
 Replacement = % Dehydration x Bodyweight
(kg) x 10
 Maintenance is the basic rate which a patient
requires during a 24 hour period. It is
commonly calculated as 50ml/kg/24hr, or
2ml/kg/hr.
 During surgery – 10ml/kg/hr is the
maintenance flow rate in small animals while
in large animal 6.6.ml/kg/hr.
 For severe dehydration- flow rate can
increase up to 30ml/kg for the first 30 minutes
then reduce to 20 ml/kg until the fluid deficit
 Ongoing losses are calculated based on a
predicted fluid amount lost by a patient within
a 24 hour period. Common losses include
vomiting and diarrhoea. It is often helpful here
if the owners are able to give a detailed history
as this makes it easier to predict the pattern of
losses. In some patients there may be no
ongoing losses and so this step can be skipped.
To calculate the fluid requirement, the
following calculation is used.
 Ongoing losses = Amount per loss
(ml/kg) x Bodyweight (kg) x No. of losses
 These calculations are then added together to
allow for the total fluid requirement in a 24
hour period. It is important to assess these
requirements on a daily basis as losses may be
increased/reduced for example.
 The calculated fluid requirement is multiplied
by the bodyweight of the individual patient to
give the total amount of fluid required for that
patient as ml/24hr period. This is then further
calculated depending on whether a drip pump
is used or fluid rate is adjusted manually as
shown below.
 Requirement per hour (ml/hr) =
Requirement per day (ml/24hr) ÷ 24
Requirement per minute (ml/min) =
Requirement per hour (ml/hr) ÷ 60

Requirement per second (ml/s)=
Requirement per minute(ml/min) ÷ 60

Drops per second = Requirement per
second (ml/s)x Giving Set Factor
Monitoring Fluid Therapy

Fluid therapy can be monitored by observing:

1. urine output,
2. Packed Cell Volume (PVC),
3. Total Protein (TP, or Total Solids, TS),
4. mucous membrane color, and
5. blood pressure among others.
It is important to also observe for signs of
oedema, such as pulmonary oedema or ascites.
It should not be stopped until hydration of the
patient has returned to normal and the patient
is able to maintain a normal hydration status
Special Considerations

 Shock
 Shock is defined as decreased oxygen
delivery or utilization by tissues that may lead
to irreversible cellular damage if prolonged.
Patients who present in a state of shock
require immediate fluid therapy. To assess
whether a patient is in shock the following
signs may be seen -
To assess whether a patient is
in shock the following signs
may be seen -
 Tachycardia
 Pale mucous membranes (May be dark if
distributive shock)
 Prolonged/Absent capillary refill time
 Reduced/Absent peripheral pulses
 Hypotension
There are 3 forms of shock:

 Hypovolemic is seen when there is reduced

circulating blood volume and the most
common form of shock.
 Cardiogenic is seen in any condition when
there is a failure for the heart to pump
effectively.
 Vascular can be sub-divided into -
 Obstructive is seen when there is an obstruction to
blood flow to a region of tissue.
 Distributive is seen when there is inappropriate
vasodilation. This leads to changes in blood flow
distribution between tissues.
 The first choice fluid in hypovolemic shock
cases are isotonic crystalloid fluids and are
given at a high flow rate. They are often
administered as a rapid bolus followed by the
high flow rate.
 In cardiogenic shock cases, often the patient
is already in volume overload and so often
treated with a diuretic. Obstructive shock is
often treated by removal of the obstruction.
Calculation of total body
fluid deficit:

Formula: % dehydration x body weight x 10

e.g. For 15 kgs. animal suffering for severe

dehydration. How many is the total fluid
needed to correct the fluid deficit?
Answer:
11 x 15 kg x 10 = 1,650 ml or 1.65 Liters
Calculation of flow rate:

IV fluid infusion using either macroset or

microset express in drops per minute.

Microset or micro drip tubing

= 60 drops/ml or 0.016 ml per drop
Macroset or macro drip tubing
= 16 drops/ml or 0.062 ml per drop
1 hour = 60 minutes
1 minute = 60 seconds

Problem: Suppose you have a 15 kgs patient

suffering from severe dehydration, what
would be the flow rate in drops per minute of
macroset/ macro drip tubing is needed for
infusion?
Infusion rate for severe dehydration:
20-30ml/kg/hr.
Formula: body wt x 20ml/hour
0.062 (macro drip)

Solution:
15 x 20ml = 300ml/hour convert 1 hour to
minute ÷ 60
15 x 20 ÷ 60 = 5ml/minute convert to drop
per minute ÷ 0.062

Answer: 81 drops/minute
For a 9 kgs patient suffering from moderate
dehydration:
 How much is the Fluid volume deficit?
 Answer: 9x9x10 = 810 ml
 Calcualte the Flow rate using a microset:
9 x 20 ml = 180ml/hr/60 = 3ml/min./0.0167
 Answer = 180 drops/ min.
Problem:

 The attending Vet. has ordered you to infuse

2000 ml of normal saline. The fluid is to be
infused over eight hours. Your infusion set
delivers 15 drops per milliliter. How many drops
per minute should be administered?
a. Multiply 2000 ml by 15 drops per ml.
Answer: 30,000 drops.
b. Multiply 8 hours by 60 minutes.
Answer: 480 minutes.
c. Divide 30,000 by 480.
Answer: 62 drops per minute.
Appropriate fluid choices:

 For Vomiting & diarrhea:

Replacement crystalloids such as LRS,
Normosol R, Plasmalyte-A
 For Hemorhage:
Natural colloids such as plasma, whole blood,
pRBCs, hetastarch
 For Cardiac disease- Low-meantenance
crystalloids such as 0.45% saline & dextrose.
 For diabetic ketoacidosis- replacement
crystalloids such as LRS, Normosol R,
Plasmalyte-A
Recommended IV Sites in dogs
& cats:
 Jugular
 Cephalic
 Lateral saphenous (recurrent tarsal)
 Medial saphenous
Complications of IV Fluid
Transfusion:
 The complications of intravenous therapy
may be mild or life threatening, but they are
always uncomfortable for the patient. Many
can be prevented with proper care.
a. Infiltration- the most frequent complication,
caused by dislodgement of the needle or
catheter or by puncture of the vein. This allows
the fluid to collect in the surrounding tissue.
Signs or symptoms include, slowing or
stopping of the intravenous flow and reduced
skin temperature in the venipuncture area. You
can restart the intravenous at another site. The
danger of this happening can be reduced by
securely taping the intravenous line and
providing arm boards for stability.
b. Speed Shock or Circulatory Overload-
Total blood volume: in dogs 80 ml/kg b.w.
in cats 70 ml/kg b.w.
Unfortunately, when too much fluid and/or too much
medication is administered too rapidly, circulatory
overload can result. Signs and symptoms include patient
pounding headache and chills, irregular pulse, and
dyspnea. It may consequently lead to congestive heart
failure & pulmonary edema.
c. Sepsis and Pyrogenic Reactions-
Sepsis and pyrogenic reactions are usually
caused by the introduction of pyrogenic
organisms or their toxins into the
bloodstream. In addition to these organisms,
febrile reactions can be caused by various
chemicals and certain types of particles. If an
infection results, the reaction can be localized
or systemic.
d. Phlebitis- is an irritation or injury to the vein. It
can be caused by mechanical, chemical, or
bacterial irritation. Signs and symptoms
include redness, pain, and swelling at the
infusion site.
e. Air Embolism- an air embolism is a very
serious intravenous therapy complication. It
can occur when a sizeable amount of air gets
into the circulatory system through the
intravenous administration set. It can block a
vessel so that tissues are unable to get oxygen.
f. Solution's Incompatibility- The signs of
incompatibility will differ according to the
solution or drug being administered. The
effects can vary from neutralizing the effects
of a drug to causing circulatory collapse.
Precautions:

a. Check all bottles or bags of infusion solution

for these specific requirements and discard
any that show:
(1) A broken vacuum seal.
(2) Cloudiness.
(3) Precipitation (particles on the bottom of the
bag or bottle).
(4) Foreign contaminants.
b. Always, use sterile equipment and observe proper aseptic
technique.
c. Disinfect the patient's skin at and around the injection
site. Apply antiseptic solution using friction at and
around the venipuncture site.
d. For long term therapy patients:
(1) Change the injection site every 48 to 72 hours (to lessen
the possibility of infection and/or irritation to the vein),
or in accordance with standard operating procedures
(SOP).
(2) Replace the tubing and solution bottle (or bag) every 24
hours (to avoid infusing a contaminated solution).
(3) Take precautions if vein irritation or thrombophlebitis is
possible.