Fluid Therapy
CONSULT THE EXPERThEMERGENCY MEDICINE & CRITICAL CAREhPEER REVIEWEDFluid TherapyAdesola Odunayo, DVM, MS, DACVECCUniversity of TennesseeFluid therapy is an essential therapeuticcomponent in small animal practice.Normal cellular function can be impairedwithout water and potentially lead topatient death.1 Intravenous fluids may beprescribed to hospitalized patients to treathypovolemia, dehydration, electrolyteimbalance, and acid-base abnormalitiesand to ensure that adequate cellularmaintenance requirements are met.2Fluid CompartmentsUnderstanding the concept of fluid compartmentscan help the clinician determine the location ofthe fluid deficit and appropriate treatment. Thebody weight of nonobese cats and dogs is com-posed of approximately 60% water.2 Puppies andkittens have higher total body water amount (ie,up to 80% of body weight), as total body waterdecreases with age.3 In addition, fat has a lowerwater content; thus, the fluid prescription shouldbe based on estimated lean body weight.4 In adultnonobese cats and dogs, approximately two-thirdsof total body water (ie, 66% of total body water or 40% of body weight) is in the intracellular space.The remaining one-third (ie, 33% of total bodywater or 20% of body weight) is in the extracellular space; of this extracellular body water, 75%( 15% of body weight) is in the interstitial spaceand 25% ( 5% of body weight) is in the intravascular space (Figure, next page). Intracellular fluidloss is generally not appreciated on physical examination and typically manifests as hypernatremia.Treatment of intracellular fluid deficit is beyondthe scope of this article.October 2018cliniciansbrief.com71
CONSULT THE EXPERTh66%EMERGENCY MEDICINE & CRITICAL CARE33%75%25% Intracelluarfluid Extracelluarfluid Interstitialfluid Intravascularfluidd FIGURE Distribution of total body water in an adult nonobese cat or dogTABLE 1PHYSICAL & LABORATORYABNORMALITIES IN PATIENTS WITHHYPOVOLEMIA & DEHYDRATIONHypovolemiaDehydrationTachycardia (bradycardia in terminalstages) in dogsPale mucous membranesWeak peripheral pulsesAltered mentationProlonged capillary refill timeCold extremitiesHypotensionElevated lactateHypothermia, bradycardia(heart rate, 160 bpm), andhypotension*Dry mucous membranesDoughy abdomenSunken eyesSkin tentingAzotemiaElevated hematocrit and totalprotein* Cats tend to demonstrate this triad.72cliniciansbrief.comOctober 2018hPEER REVIEWEDIntravascular fluid deficit (ie, hypovolemia)leads to inadequate oxygen delivery to thecells (ie, poor perfusion or shock). Untreatedintravascular fluid deficit can be life-threatening, as oxygen is important for minute-to-minute cellular function maintenance. Inadequateoxygen delivery can lead to hyperlactatemiathrough anaerobic glycolysis, cell membranedisruption, cell death, and organ death.5Physical examination findings of hypovolemia(Table 1) include tachycardia in dogs, bradycardia in cats (and in the terminal stages ofshock in dogs), prolonged capillary refill time,pale mucous membranes, weak peripheralpulses, cold extremities, and altered mentalstate. Patients exhibiting these signs requireemergent treatment to rapidly restore oxygendelivery. Common clinical conditions that leadto intravascular fluid loss include hemorrhagesecondary to trauma, coagulopathy, neoplasia,gastroenteritis, pancreatitis, and peritonitis.Interstitial fluid deficit (ie, dehydration)is commonly assessed based on a percentageof the estimated interstitial fluid lost (Table2) and typically does not result in life-threatening abnormalities unless dehydration progresses to approximately 9% or greater. Signsof dehydration that may be identified onphysical examination include skin tenting,dry mucous membranes, doughy abdomen,and sunken eyes. The different clinicalapproaches and urgency for treating poorperfusion and dehydration make differentiating between them vital (Table 1).Fluid TypesA crystalloid is a water-based solution composed of osmotically active small moleculesthat are permeable to the capillary.6 A significant percentage of crystalloids move into theinterstitial and intracellular space withinapproximately 45 minutes of intravenousadministration. Isotonic crystalloids (eg,0.9% NaCl, lactated Ringer’s solution), whichare primarily used for fluid therapy in veteri-
nary medicine, have osmolality similar toplasma and therefore do not cause cellularswelling or shrinkage when administered.6Hypotonic and hypertonic crystalloids havelower and higher osmolality, respectively, ascompared with plasma.Synthetic colloids (eg, hydroxyethyl starchsolutions) are crystalloid-based fluids composed of large molecules that do not cross thecapillary membrane. Colloids can be used totreat hypovolemia and/or hypoproteinemia.7-9Synthetic colloids should be used cautiouslyin veterinary patients10,11 because of concernsin human patients that acute kidney diseaseand coagulopathies may develop.Fluid PrescriptionA quick stepwise approach that provides anindividualized fluid plan for the patient isneeded once it has been determined that fluidtherapy may be beneficial. Using a fluid prescription consisting of 3 straightforward steps(vs arbitrarily putting a patient on a 2 maintenance fluid rate) ensures that the patient’sfluid deficit is identified and corrected in atimely manner (see Examples of Individualized Fluid Plans, page 75). Ongoing fluidlosses are not included in this plan but shouldbe replaced in patients with significant ongoing fluid loss (eg, a puppy with parvoviralenteritis with continued vomiting and diarrhea).Hypovolemia and dehydration can occur independently of each other; therefore, dehydratedpatients may not be hypovolemic, and hypovolemic patients may not be dehydrated.Step 1: Resuscitation (Identify & TreatHypovolemia if Present)Hypovolemia can lead to poor oxygen delivery and should be identified (Table 1) andtreated quickly.12 If hypovolemia is suspectedor identified, fluids should be administeredintravenously or via the intraosseous route.TABLE 2PHYSICAL EXAMINATIONFINDINGS OF DEHYDRATION& ESTIMATE OF FLUID LOSSPERCENTAGEDehydrationPercentagePhysical Examination Findings 5%Dehydration is not clinicallydetectable, but patient hashistory of fluid loss5%-7%Dry mucous membranesSkin tenting7%-9%Dry mucous membranesSkin tentingSunken eyesDoughy abdomen9%-12%Dry mucous membranesSkin tentingSunken eyesDoughy abdomenEvidence of hypovolemia maybe present12%-15%*Dry mucous membranesSkin tentingSunken eyesDoughy abdomenEvidence of hypovolemia ispresent* Death is imminent.Like any drug used inclinical medicine, fluidsare not benign, andtheir use can potentiallylead to life-threateningcomplications.October 2018cliniciansbrief.com73
CONSULT THE EXPERThEMERGENCY MEDICINE & CRITICAL CAREFluids administered subcutaneously, in theperitoneal cavity, or through the oral routeare not absorbed well because blood flow isdiverted to the heart, lungs, and brain in ahypovolemic state. Cats with evidence ofhypovolemia should be actively warmed to abody temperature of at least 97 F (36 C)before large volumes of fluids are given.The shock dose is an estimate of the total bloodvolume (dogs, 90 mL/kg/hr; cats, 60 mL/kg/hr). It is unlikely that a hypovolemic patientwill have lost its entire blood volume; thus,approximately 25% of the fluid prescription(dogs, 20 mL/kg/15 min; cats, 15 mL/kg/15min13) should be administered using pressurebags, fluid pumps, or a 60-mL syringe. Fluidpumps run at 999 mL/hr and are best used forboluses when the total volume to be infusedover 15 minutes is less than 250 mL.The patient should be re-evaluated after thefluid bolus is given. Additional fluid bolusescan be administered (dogs, 90 mL/kg/hr;cats, 60 mL/kg/hr) if clinical parameters ofhypovolemia have improved but are not yetsatisfactory (see Oxygen Delivery Restoration Parameters). Fluid administrationOXYGEN DELIVERYRESTORATION PARAMETERShNormal heart rate (dogs, 100-140 bpm;cats, 160 bpm)hPink mucous membraneshNormal capillary refill time ( 2 seconds)hNormal peripheral pulseshImproved mentationhImproved blood pressure (100-140 mm Hgsystolic)hImproved serum lactate (1-2.5 mmol/L)hPEER REVIEWEDcan be discontinued when the patient has metthe desired criteria, but, because isotoniccrystalloids have a short lifespan in the intravascular space, the patient’s vital parametersshould be monitored closely.Synthetic colloids (eg, hydroxyethyl starchsolutions; 1-5 mL/kg every 15 minutes) canbe used to treat hypovolemia. The authorprefers to use the low end of the dose rangefor cats, whereas dogs tend to tolerate thehigher end.Step 2: Rehydration (Identify & TreatDehydration if Present)After hypovolemia (if present) is treated, thepatient should be evaluated (Table 1, page 72)and treated for dehydration as needed. Thefluid deficit in the interstitial space can bedetermined by multiplying the patient’s bodyweight by the estimated dehydration percentage (Table 2, previous page)1:Fluid deficit (liters) weight in kg % dehydrationThe fluid deficit is then replaced over a periodof 6 to 24 hours1 using any isotonic crystalloid. The author prefers to replenish the fluiddeficit over 6 to 8 hours except in cats and inpatients with underlying heart disease, inwhich the fluid deficit is replaced over 12 to24 hours.Step 3: Maintenance (Provide CellularMaintenance Requirement)Cells have a daily water requirement to maintain regular metabolism. Maintenance fluids(dogs, 60 mL/kg/q24h; cats, 45 mL/kg/q24h12)can be provided as part of the fluid plan when apatient is not eating or drinking, in addition tocorrecting dehydration and restoring perfusion. Multiple units of the maintenance dose(rates 2 or more above the maintenance rate)can be provided to patients that may benefitContinues on page 7674cliniciansbrief.comOctober 2018
CONSULT THE EXPERThEMERGENCY MEDICINE & CRITICAL CAREVETORYL CAPSULES(trilostane)5 mg, 10 mg, 30 mg, 60 mg and 120 mg strengthsAdrenocortical suppressant for oral use in dogs only.BRIEF SUMMARY (For Full Prescribing Information,see package insert.)from diuresis (eg, after exposure to toxins). Isotonic crystalloids aretypically used to provide maintenance requirements, but hypotoniccrystalloids (eg, 0.45% NaCl) may also be used.Complications of Fluid TherapyLike any drug used in clinical medicine, fluids are not benign, andtheir use can potentially lead to life-threatening complications,including respiratory distress secondary to volume overload,coagulopathies, electrolyte abnormalities, acid-base disturbances, and propagation of inflammation.14 Fluid prescriptionsshould be individualized and the patient monitored often todetect any adverse effects associated with fluid therapy. nReferences1. Mazzaferro E, Powell LL. Fluid therapy for the emergent small animal patient: crystalloids,colloids, and albumin products. Vet Clin North Am Small Anim Pract. 2013;43(4):721-734.2. Mensack S. Fluid therapy: options and rational administration. Vet Clin North Am SmallAnim Pract. 2008;38(3):575-586.3. Macintire DK. Pediatric fluid therapy. Vet Clin North Am Small Anim Pract. 2008;38(3):621627.4. Wellman ML, DiBartola SP, Kohn CW. Applied physiology of body fluids in dogs and cats. In:DiBartola SP, ed. Fluid, Electrolyte, and Acid-Base Disorders in Small Animal Practice. 4th ed.St. Louis, MO: WB Saunders; 2012:2-25.5. Pang DS, Boysen S. Lactate in veterinary critical care: pathophysiology and management.J Am Anim Hosp Assoc. 2007;43(5):270-279.6. Rudloff E, Kirby R. Fluid therapy. Crystalloids and colloids. Vet Clin North Am Small AnimPract. 1998;28(2):297-328.7. Mandell DC, King LG. Fluid therapy in shock. Vet Clin North Am Small Anim Pract.1998;28(3):623-644.8. Chan DL. Colloids: current recommendations. Vet Clin North Am Small Anim Pract.2008;38(3):587-593.9. Kasper SM, Meinert P, Kampe S, et al. Large-dose hydroxyethyl starch 130/0.4 does notincrease blood loss and transfusion requirements in coronary artery bypass surgerycompared with hydroxyethyl starch 200/0.5 at recommended doses. Anesthesiology.2003;99(1):42-47.10. Hayes G, Benedicenti L, Mathews K. Retrospective cohort study on the incidence ofacute kidney injury and death following hydroxyethyl starch (HES 10% 250/0.5/5:1)administration in dogs (2007–2010). J Vet Emerg Crit Care (San Antonio). 2016;26(1):35-40.11. Reinhart K, Perner A, Sprung CL, et al. Consensus statement of the ESICM task force oncolloid volume therapy in critically ill patients. Intensive Care Med. 2012;38(3):368-383.12. Brown AJ, Otto CM. Fluid therapy in vomiting and diarrhea. Vet Clin North Am Small AnimPract. 2008;38(3):653-675.13. Davis H, Jensen T, Johnson A, et al. 2013 AAHA/AAFP fluid therapy guidelines for dogs andcats. J Am Anim Hosp Assoc. 2013;49(3):149-159.14. Mazzaferro EM. Complications of fluid therapy. Vet Clin North Am Small Anim Pract.2008;38(3):607-619.CAUTION: Federal (USA) law restricts this drug touse by or on the order of a licensed veterinarian.DESCRIPTION: VETORYL Capsules are an orallyactive synthetic steroid analogue that blocksproduction of hormones produced in the adrenalcortex of dogs.INDICATION: VETORYL Capsules are indicated forthe treatment of pituitary- and adrenal-dependenthyperadrenocorticism in dogs.CONTRAINDICATIONS: The use of VETORYLCapsules is contraindicated in dogs that havedemonstrated hypersensitivity to trilostane. Do notuse VETORYL Capsules in animals with primaryhepatic disease or renal insufficiency. Do not use inpregnant dogs. Studies conducted with trilostane inlaboratory animals have shown teratogenic effectsand early pregnancy loss.WARNINGS: In case of overdosage, symptomatictreatment of hypoadrenocorticism withcorticosteroids, mineralocorticoids and intravenousfluids may be required. Angiotensin convertingenzyme (ACE) inhibitors should be used with cautionwith VETORYL Capsules, as both drugs havealdosterone-lowering effects which may be additive,impairing the patient’s ability to maintain normalelectrolytes, blood volume and renal perfusion.Potassium sparing diuretics (e.g. spironolactone)should not be used with VETORYL Capsules asboth drugs have the potential to inhibit aldosterone,increasing the likelihood of hyperkalemia.HUMAN WARNINGS: Keep out of reach of children.Not for human use. Wash hands after use. Do notempty capsule contents and do not attempt to dividethe capsules. Do not handle the capsules if pregnantor if trying to conceive. Trilostane is associated withteratogenic effects and early pregnancy loss inlaboratory animals. In the event of accidentalingestion/overdose, seek medical advice immediatelyand take the labeled container with you.PRECAUTIONS: Hypoadrenocorticism can developat any dose of VETORYL Capsules. A smallpercentage of dogs may develop corticosteroidwithdrawal syndrome within 10 days of startingtreatment. Mitotane (o,p’-DDD) treatment will reduceadrenal function. Experience in foreign marketssuggests that when mitotane therapy is stopped, aninterval of at least one month should elapse beforethe introduction of VETORYL Capsules. The use ofVETORYL Capsules will not affect the adrenal tumoritself. Adrenalectomy should be considered as anoption for cases that are good surgical candidates.The safe use of this drug has not been evaluated inlactating dogs and males intended for breeding.ADVERSE REACTIONS: The most common adversereactions reported are poor/reduced appetite,vomiting, lethargy/dullness, diarrhea, elevated liverenzymes, elevated potassium with or without decreased sodium, elevated BUN, decreased Na/Kratio, weakness, elevated creatinine, shaking, andrenal insufficiency. Occasionally, more seriousreactions, including severe depression, hemorrhagicdiarrhea, collapse, hypoadrenocortical crisis oradrenal necrosis/rupture may occur, and may resultin death.Distributed by:Dechra Veterinary Products7015 College Boulevard, Suite 525Overland Park, KS 66211VETORYL is a trademark ofDechra Ltd. 2015, Dechra Ltd.NADA 141-291, Approved by FDA76cliniciansbrief.comOctober 2018
EXAMPLES OF INDIVIDUALIZED FLUID PLANSEXAMPLE 1Gerald, a 4-year-old neutered male catweighing 6.6 lb (3 kg), is presented forvomiting and diarrhea of 3 days’ duration.He was anorexic and lethargic prior topresentation.On physical examination, Gerald is quietand has a heart rate of 120 bpm, palemucous membranes with a capillary refilltime of about 2 seconds, weak peripheralpulses, initial blood pressure of 50 mm Hg(systolic), and a body temperature of 94 F(34 C). He is also estimated to be about6% dehydrated based on skin tenting anddry mucous membranes.STEP 1: RESUSCITATIONGerald has signs of hypovolemia (ie,bradycardia, hypotension, hypothermia,weak peripheral pulses, pale mucousmembranes) and should be resuscitatedimmediately to restore oxygen delivery.h A peripheral catheter—or intraosseous catheter if a peripheral catheter isdifficult to place—should be used. Themedial saphenous veins may be easierto access in hypovolemic cats.h Exogenous heating (eg, forced airEXAMPLE 2Sasha, a 4-year-old female Dachshundweighing 15.4 lb (7 kg), is presentedfor evaluation after being hit by a car.Physical examination findings reveala heart rate of 160 bpm, pale mucousmembranes, a capillary refill time of 3seconds, and weak peripheral pulses.She has a broken left femur and someabrasions associated with the fracture.The remainder of the findings are withinnormal limits.STEP 1: RESUSCITATIONSasha has signs of hypovolemia (ie,poor perfusion) based on tachycardia,prolonged capillary refill time, and weakperipheral pulses.warming devices) should be used toraise body temperature to at least97 F (36 C).h A 45-mL (15-mL/kg) balanced isotoniccrystalloid (eg, lactated Ringer’ssolution, 0.9% NaCl) should be administered over 15 minutes using a 60-mLsyringe or a fluid pump.h Parameters should be reassessed andstopped if the patient has met the endgoals (see Oxygen Delivery Restoration Parameters).h As the patient’s body temperaturerises, additional fluid boluses can begiven, if needed.STEP 2: REHYDRATIONGerald responded well to the fluid givenduring resuscitation. His heart rate is now200 bpm, blood pressure is 100 mm Hg,and mucous membranes are pink. Hestill has signs of dehydration based onskin tenting and dry mucous membranesand is estimated at 6% dehydration. Thisfluid deficit should be replaced using anisotonic crystalloid.h Fluid deficit calculation: Fluid deficit (liters) weight in kg (3) % dehydration (0.06)h A large-bore intravenous cathetershould be placed and fluid therapyinitiated to restore oxygen delivery.An analgesic—ideally opioids—shouldbe administered for fracture-associated pain that may also lead totachycardia.h A 140-mL isotonic crystalloid bolusshould be administered (20 mL/kg)rapidly over 15 minutes. A fluid pumpmay be used.h Physical examination parametersshould be reassessed to ensure endgoals (see Oxygen Delivery Restoration Parameters) have been metafter providing a fluid bolus. The crystalloid dose may be repeated up to90 mL/kg/hr.Fluid deficit 3 0.06Fluid deficit 0.18 L (180 mL)h Timeframe needed to replace the fluiddeficit (cats tend to be less fluid tolerant; Gerald’s deficit will be replacedover 12 hours):180 mL q12h 15 mL/hr for 12 hoursSTEP 3: MAINTENANCEHourly fluid requirements (ie, maintenance fluids) should be provided to maintain normal cellular activity. Becausethe patient is not eating or drinking, themaintenance requirement should beprovided using an isotonic crystalloid; ahypotonic crystalloid can also be used toprovide maintenance requirements.h The maintenance fluid requirement is:45 mL/kg q24h (45 3) 135 mL/q24hor 6 mL/hrh Overall fluid prescription after treatinghypovolemia is:Fluid deficit (15 mL/hr) maintenance(6 mL/hr) 21 mL/hr for the first 12hours; fluid rate is then reduced to 6mL/hr (provided there are no ongoingfluid losses)STEP 2: REHYDRATIONPhysical examination findings consistentwith dehydration are not found. This stepcan be skipped.STEP 3: MAINTENANCEBecause Sasha is not likely to begin eating or drinking immediately, she will likelybenefit from maintenance fluids.h Maintenance fluid requirement is:60 mL/kg q24h (60 7) 420 mL q24hor 18 mL/hrh Overall fluid prescription after treatinghypovolemia is:Fluid deficit (0 mL/hr) maintenance(18 mL/hr) 18 mL/hr until she startsto eat and drink on her own (providedthere are no ongoing fluid losses)October 2018cliniciansbrief.com75
Fluid Prescription A quick stepwise approach that provides an individualized fluid plan for the patient is needed once it has been determined that fluid therapy may be beneficial. Using a fluid pre-scription consisting of 3 straightforward steps (vs arbitrarily putting a patient on a 2 main - tenance fluid rate) ensures that the patient’s
L M A B CVT Revision: December 2006 2007 Sentra CVT FLUID PFP:KLE50 Checking CVT Fluid UCS005XN FLUID LEVEL CHECK Fluid level should be checked with the fluid warmed up to 50 to 80 C (122 to 176 F). 1. Check for fluid leakage. 2. With the engine warmed up, drive the vehicle to warm up the CVT fluid. When ambient temperature is 20 C (68 F .
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