FLUID

THERAPY
JoAnne M. Roesner DVM,
DABVP
Loving Hands Animal Clinic
Alpharetta, GA
www.lovinghands.com
joanne.roesner@lovinghands.
com

Thanks to Schering-Plough
for sponsoring this lecture!

Body Water and Fluid

Compartments
TBW = 0.6 x kg
TBW = ECF + ICF
(1/3) (2/3)
ECF = extracellular, ICF = intracellular
ECF = Interstitial + Plasma
(1/3)
(1/4)
Fluid spaces are iso-osmolar due to water
movement
(Greco, Vet Clinics, 1998)

Fluid Movement

Net filtration at arteriolar end

Net re-adsorption at venuli end
Inflammation causes increased vascular
permeability
(Greco, Vet Clinics, 1998)

Why give fluids?

Replace intravascular volume

Improve tissue perfusion
Replace fluid deficits (dehydration)
Meet maintenance in NPO patient
Replace ongoing losses (V, D, burns, etc.)
Fluid diuresis to eliminate toxins
Anesthetic and surgical support
Replacement of specific components (blood,
plasma)
Nutritional support (TPN, PPN)
(Mensach IVECCS, 2005)

Examples of Fluid Loss

Puregastric vomiting: loss of HCl; volume
causes hypochloremic metabolic alkalosis (Cl
decrease limits re-adsorption of HCO3 in
kidneys
Bilious vomiting: loss of K, HCO3, Na; causes
hypokalemia, acidosis (Color of vomit is
important!)
Panting: loss of free water; no electrolyte loss
PD: free water gain; dilution and diuresis
promote ion loss
Diarrhea: volume; Na, K, HCO3

Routes of Fluid
Administration
Subcutaneous:
-

not for sever dehydration or shock

not if potential vasoconstriction
crystalloids only
no dextrose
K+ is painful
10-20 ml/kg/site
aseptic technique

Routes of Fluid
Administration

Enteral:
- limited by patients ability to handle
- can use to prevent gut-atrophy
- trickle feeding
- can combine with other methods (NG tube,
etc.)
- BES + K + dextrose + food coloring
Intraperitoneal:
- fairly rapid adsorption
- aseptic technique
- warm fluids
(Mensach, IVECCS, 2005; Matthews, Vet Clinics, 1998.)

Routes of Fluid
Administration

Intraosseous:
- similar to IV
- useful especially in neonates and small patients
Intravenous:
- peripheral vs. central line
- moderate/severe dehydration, shock
- cutdowns (20G needle technique)
- change catheters every 72 hours
- CVP ballparking it
- bolus vs. CRI
- crystalloids, colloids, blood products, IV feeding
(Mensach, IVECCS, 2005; Matthews, Vet Clinics, 1998)

Maintenance Fluid Rates

Only an estimate
Consider sensible (urine, feces) and insensible fluid
losses
Do not consider other potential losses (PUPD, V, D)
Calculations:
1 ml/lb/h
66 ml/kg/d for dogs
44 ml/kg/d for cats
30 ml/lb/day
(30 x kg) + 70 (also = RER)
Measure ins and outs and add 2 ml/kg/hr for
insensible

Fluid Deficits
Replace with BES (type determined by
source of losses)
Replace over 24 hours (in addition to
maintenace route)
Rapid replacement can result in cerebral
edema when losses are chronic (idiogenic
osmoles)
Deficit (ml) = % dehydration x kg x 1000
(Matthews, Vet Clinics, 1998)

Shock Fluid Rates

Goal is rapid repletion of vascular volume
Best to use physiologic endpoints rather
than rote formula (BP, HR, CRT, etc.)
Dog: up to 90 ml/kg crystalloid
Cat: up to 40 ml/kg crystalloid
Consider adding colloids, hypertonic
saline

Intra-operative Fluid
Rates

5 ml/kg/h for procedures involving

minimal blood loss
10 ml/kg/h for more extensive procedures
or those with greater blood loss
(Mensach, IVECCS, 2005)

Monitoring Fluid Therapy

Serial exams: vascular fullness,
membrane moisture, skin turgor,
auscultation, CRT, pulse quality, HR, RR
Urine: specific gravity, volume
Blood pressure
Body weight
Labs: electrolytes, PCV, TS, BUN,
Creatinine, lactate (tissue perfusion)
CVP
(Mensach, IVECCS, 2005; Hughes, IVECCS, 2005)

Serum Electrolytes
SODIUM
Extracellular: major determinant of plasma
tonicity, low Na means too much free water in
blood, high Na means too little free water,
must address abnormalities to prevent brain
swelling or shrinking
ADH : released from posterior pituitary in
response to increased plasma osmolarity,
causes water re-adsorption in kidney
Aldosterone: released from adrenal gland,
causes water re-adsorption in kidney, Na
conservation, K excretion
(Dibartola, Marks, Vet Clinics, 1998)

Serum Electrolytes
CHLORIDE
Primary extracellular anion
Levels typically parallel Na
Low Cl prevents HCO3 re-adsorption in
kidney and exacerbates alkalosis
(Dibartola, Marks, Vet Clinics, 1998)

Serum Electrolytes
POTASSIUM
Intracellular cation, Na K ATPase (Mg =
cofactor)
Hypokalemia common, especially in cats
Maximum rate of administration 0.5 mEq/kg/h
Maintenace is 20 mEq/L of BES
Translocation alters serum levels (e.g. acidosis
causes movement out of cells, insulin causes
movement into cells)
Aldosterone promote K excretion (Na readsorption)

Serum Electrolytes
POTASSIUM
Low Mg promotes K excretion
Serum levels do not reflect body stores
Low K: weakness, droopy neck, long QT,
interval, decreased T waves
High K: weakness, spiked T waves, wide
QRS, decreased P waves
(Phillips and Polzin, Vet Clinics, 1998)

Serum Electrolytes

MAGNESIUM
Most common electrolyte abnormality n
hospitalized humans is hypomagnesimia
Primarily intracellular
Low Mg may be clinically silent but makes
hypocalcemia and hypokalemia refractory
to treatment
Vitamin D controls Mg absorption
May see high Mg in renal failure

Serum Electrolytes
MAGNESIUM
Normosol and Plasmalyte contain Mg
Very low Mg may require treatment with
IV MgSO4
Cofactor for NaK ATPase
(Martin, Vet Clinics, 1998; Dhupa and Proulx, Vet Clinics, 1998)

Serum Electrolytes

BICARBONATE
Major plasma buffer along with proteins
Metabolic component of acid/base
disorders
Will precipitate with Ca (do not add to LRS)
Mild abnormalities resolve with fluid repletion
and improved perfusion
Always under correct base deficits (organic
acids are metabolized with improved
perfusion i.e. dont need to neutralize)
Normal dogs ~ 18-24
(Bailey and Pablo, Vet Clinics, 1998)

Serum Electrolytes
PHOSPATE
Hyperphosphatemia: common in CRF, can occur with
primary parathyroid disease and cancer (PTHrp)
Hypophosphatemia: seen with diuresis, TPN, hepatic
lipidosis, treated DKA (especially cats) alkalosis
Clinical signs may be profound:
- neuro, cardiac, hemolysis (ATP, 2-3 DPG etc.
mediated)
- Therapy/prevention: replace half of daily K as K 2PO4

- Enteral cows milk

Types of Fluids
1. Crystalloids: replacement solutions,
maintenance solutions, hypertonic
saline
2. D5W
3. Colloids
4. Blood products
5. TPN and PPN
(Matthews, Vet Clinics, May 1998; Mensach, 11th IVECCS
Proceedings, 2005)

Crystalloids
Water with Na or glucose, base source,
electrolytes
Short intravascular retention equilibrate with
intracellular and interstitial compartments
Base source (Na++CO3-):
lactate: liver metabolism
acetate: muscle metabolism
gluconate: metabolism in most body tissue
(Matthews, Vet Clinics, May 1998; Mensach 11th IVECCS
Proceedings, 2005)

Tonicity
Isotonic: approximate osmolarity of blood
and ECF, does not cause swelling or
shrinking of RBC when infused (e.g. LRS)
Hypertonic: osmolarity higher than ECF
and blood, can shrink RBC and dehydrate
intracellular and interstitial fluid
Hypotonic: osmolarity lower than ECF and
blood, may swell RBC and cause edema
(Matthews, Vet Clinics, May 1998; Mensach, 11th IVECCS 2005)

Replacement Solutions
Either alkalinizing or acidifying
Solute concentration ~ plasma water
concentration
Used to rapidly replace intravascular fluid
and electrolytes (e.g. GI disease, 3rd
spacing, +/- hemmorrhage, shock), used
to replace fluid deficits
20-25% stays within vascular space 1
hour post infusion

Replacement Solutions
Consider source of loss (e.g. pure gastric
vs. bilious vomiting) when choosing a
fluid
Fluid deficit (liters) = % dehydration x kg
Examples:
LRS
0.9% NaCl
Plasmalyte A
Normosol-R
(Matthews, Vet Clinics, May 1998; Mensach, 11th IVECCS 2005)

Lactated Ringers
Solution (LRS)

Isotonic
Alakalinzing 28 mEq/L of bicarb precursors
Na+ lower than plasma (130 mEq/L)
K+ is low (4 mEq/L)
No Mg2+
Cl- is relatively high (119 mEq/L0
Ca2+ is 3 mEq/L
(Matthews, Vet Clinics, May 1998, p. 483)

Lactated Ringers
Solution (LRS)
Lactate must be metabolized in liver, may
already be high in patient with hypoperfusion
Calcium will precipitate if add NaHCO3,
chelating anticoagulants and some drugs
Consider adding 16 mEq/L KCL if used as a
maintenance fluid (i.e. total 20 mEq/L K+)
Add free water source if used as maintenace
Useful choice for diuresis replacement of
isotonic or slightly hypotonic fluid losses,
vascular volume repletion
(Matthews, Vet Clinics, May 1998, p. 483)

L-LRS vs. Raceemic (D-L)

LRS

Most LRS is racemic

L-LRS is available from Baxter
D-isomer is pro-inflammatory

L-isomer is not inflammatory

Ketone Ringers (betahydroxybutyrate
relace lactate as buffer) also less
inflammatory
(Wall, IVECCS, 2005)

Ringers Ethyl Pyruvate

Better restoration of splanich flow
Decreased intestinal hyperpermeability
Decrease NF Kappa B activation
(Wall, IVECCS, 2005)

Normal Saline (0.9%

NaCl)

Isotonic, acidifying
Na and Cl = 154 mEq/L
No Ca or Mg
Can add HCO3, PO4 safely
Useful to treat alkalosis (pure gastric
vomiting, furosemide overdose)

(Matthews, Vet Clinics, May 1998; Mensach, IVECCS, 2005)

Normal Saline (0.9%

NaCl)

Useful to treat hypercalcemia and

hyperkalemia (Addisons) and
bodywide Na depletion (diabetes/DKA)
and initially in sever hypernatremia
May need potassium supplement
contra-indicated in volume overload
(CHF, hypertension, liver disease with
Na retention)
(Matthews, Vet Clinics, May 1998; Mensach, IVECCS, 2005)

Normosol R
Isotonic

- Na = 140 mEq/L
- K = 5 mEq/L
- Cl = 98 mEq/L
- Mg = 3 mEq/L
May add HCO3, PO4, some
alkalinizing drugs
Acetate is buffer (16 mEq/L)
(Matthews, Vet Clinics, May 1998; Mensach, IVECCS, 2005)

Normosol R
Useful in a wide variety of situations
Useful in liver disease because acetate is
metabolized in muscle
Not enough Mg to treat hypomagnesemia
but may prevent it
Use cautiously with renal disease as Mg
may already be high
(Matthews, Vet Clinics, May 1998; Mensach, IVECCS, 2005)

Maintenance Solutions
Use after fluid deficits have been replaced
Solute concentration approximates ECF,
meets normal maintenace losses
Hypotonic
Less than 10% remains in vascular space
after 1 hour
Most need potassium supplementation
e.g. Normosol M, Plasmalyte 56, 0.45%
NaCl and 1/2 D5W and LRS
(Matthews, Vet Clinics, May 1998; Mensach, IVECCS, 2005)

Hypertonic Saline
7.5-23% NaCl
Used to rapidly expand vascular volume
(e.g. severe hypovolemia with impending
death, low volume resuscitation in head
trauma, GDV (cannot get fluids in fast
enough))
Dogs 4-8 ml/kg, cats 204 ml/kg at 1
ml/kg/minute
Lasts 30 minutes intravascularly
Follow with crystalloids, colloids
(Matthews, Vet Clinics, May 1998; Mensach, IVECCS, 2005)

Hypertonic Saline
Contra-indications: dehydration, heart or
liver disease, uncontrolled hemorrhage
Monitor cardiovascular parameters
(negative inotrope, lasts for approximately
10 minutes post-infusion)
May decrease re-perfusion injury by
reducing calcium entry into cells
Decreases endothelial swelling and
dysfunction
Can combine with colloids
(Matthews, Vet Clinics, May 1998; Mensach, IVECCS, 2005)

D5W
Isotonic
Source of free water
NOT balanced (No Na, K, Mg, Cl)
No buffer source
Vehicle for drug infusion
Not a significant calorie source
Used with mixed replacement
solutions to create maintenace fluids
(Matthews, Vet Clinics, May 1998; Mensach, IVECCS, 2005)

D5W
Free water deficit:
Liters = 0.6 x kg ((1-42)/Patient Na)
Plasma osmolality = 2(Na + K) + BUN/18 +
Glucose
(DiBartola, Vet Clinics, 1998; Marks and Taboada, Vet Clinics,
1998.)

Colloids
Contain large molecules which do not
diffuse freely from intravascular
compartment
Oncotic pressure proportional to number
of particles
Expand vascular volume
Hypovolemic resuscitation (e.g. head
trauma, 3rd spacing)
(Matthews, Vet Clinics, May 1998; Mensach, IVECCS, 2005)

Colloids
Inflammatory disease (pancreatitis, SIRS,
sepsis, etc.)
Synthetic and natural
(Matthews, Vet Clinics, May 1998; Mensach, IVECCS, 2005)

Colloids
Relatively contra-indicated in CHF or
oliguric/anuric RF
May decrease clotting factor activity with
synthetic colloids, but low clinic risk with
products available currently
Monitor if use synthetic colloids in
patients with pre-existing coagulopathy

Capillary Leak Syndrome

Present in inflammation
Results in tissue edema -> organ
dysfunction -> MODS
Colloids help ameliorate via: plug
endothelial gaps with large molecule,
down regulate adhesins (e.g. ICAM-1,
selectin)
(Chan, IVECCS, 2005)

Plasma
Midwest Animal Blood Services Inc.
(517)851-8244
Feline FFP
25 ml/unit
$110
(4/05)
Canine FFP
210 ml/unit $165
Canine Cryopoor P
100ml/unit
$66
Shelf life is one year

Plasma
FFP: all clotting factors, ATIII alpha-2
macroglobulin, etc. + albumin
Cryopoor Plasma: lacks factor VIII etc.,
still has albumin, other clotting factors
(ATIII)
22.5 ml/kg of plasma will raise patient
albumin 5g/L
May need to combine with sythetic
colloids in inflammation
(Matthews, Vet Clinics, May 1998; Mensach, IVECCS, 2005)

Plasma
Controversial: incubate with heparin (10100 u/kg) for 30 minutes in DIC
Volume: 20-30 ml/kg/day
Infuse over 4-24 hours
(Matthews, Vet Clinics, May 1998; Mensach, IVECCS, 2005)

Albumin
Source of oncotic pressure in plasma
Leaks in inflammation
1 g albumin retains 18 ml of fluid in
intravascular space
Normal distribution: 40% intravascular,
60% interstitial
Hepatic synthesis regulated by
osmoreceptors in interstitium, not by
blood levels
(Matthews, Vet Clinics, May 1998; Mensach, IVECCS, 2005)

Albumin
t = 8-9 days in man
Carries drugs and endogenous
substanecs
Scavenges free radicals, reactive oxygen
species, Fe
Helps to maintain vascular integrity
(Matthews, Vet Clinics, May 1998; Mensach, IVECCS, 2005)

25% Human Serum Albumin

(HAS)

May have anti-inflammatory benefit

(decreased macrophage activation and
PMN oxygen burst, CD 18 down regulation)
Use peripheral or central line
OVC in Geulph 200 cases: 2-4 ml/kg at rate
of 0.1-1.7 ml/kg/h, monitor BP, HR, RR, T,
edema, anaphylaxis
Plasbumin Bayer
Long-term effects still under investigation
(Matthews, Vet Clinics, May 1998; Mensach, IVECCS, 2005)

Hetastarch (HES)
Synthetic colloid, plant starch
Degraded by amylase, rate is proportional to
degree of hydroxyl substitution
Dogs at 20 ml/kg/day say changes in clotting
tests but no clinical effects
USA: 6% HES (450 KDa/0.7 C2:C6)
Europe: lower MW higher substitution
products
less coagulation change, balanced
electrolyte solution less inflammatory
(Chan, IVECCS, 2005)

Hetastarch (HES)
Dose:
Dog 20 ml/kg/day (up to 40 ml/kg/day)
Cat 5-10 ml/kg/day
After initial volume administration can mix
with crystalloids in a ratio of 30%
HES:70% crystalloid x rate of fluids
Monitor for overhydration with all
synthetic colloids
(Matthews, Vet Clinics, 1998; Chan, IVECCS, 2005.)

Hemoglobin Based Oxygen

Carriers (HBOCs)
Oxyglobin Biopure
Hemopure Biopure (future product?)
PolyHeme Northfield Labs (under
development)
Sangart Product (under development)
(Wall, IVECCS, 2005)

HBOC Oxyglobin
Bovine Hb solution
Unloads O2 according to Cl tension
Access to microcucultation (smaller than
RBC)
Potent colloid give slowly and at lower
volume than in cats
Stable at room temperature
Do not freeze
(Matthews, Vet Clinics, 1998; Mensach, IVECCS, 2005; Wall,
IVECCS, 2005.)

HBOC Oxyglobin
Forms methemoglobin with storage after
opening
Dose: 10-30 ml/kg (dog)
Discolors urine and patient
Interferes with some lab tests
(Matthews, Vet Clinics, 1998; Mensach, IVECCS, 2005; Wall,
IVECCS, 2005)

Total Parenteral Nutrition

(TPN)

Meet total caloric needs via IV solutions

Must use central line
Absolute aseptic technique
Gut atrophy and bacterial/toxin
translocators
Hypertonic solutions, lipid containing
Complications: vasculitis, thrombosis
Ebb and flow phases of stressed starvation
(hypermetabolism)
(Mazzaferro, Multidisciplinary Review, 2004)

Partial Parenteral Nutrition

(PPN)

Use to meet part of RER

Aminoacids, electrolytes (K, Mg, PO4)
carbohydrates +/- lipids
Peripheral line if < 5.50 mOsm/L dedicated
line is best (my preference is BES 1 line
PPN in 2nd line at maintenance rate)
Need to monitor electrolytes
Add B vitamins
(Mazzaferro, 2004; Matthews, Vet Clinics, 1998; Mensach,
IVECCS, 2005)

Partial Parenteral Nutrition

(PPN)

RER = (30 x kg) + 70, goal 25-50% RER

Give energy via Dextrose (80-100%) lipids
(20%)
Dog: 3g protein per 100 Kcal
Cat: 4 g protein per 100 Kcal, add taurine
Consider adding Mg (0.75 mEq/kg/day), PO4 (add
of supplemental K requirements as K2PO4) and
K+
5% Dextrose (100 ml 50% ex to 900 ml BES =
0.17 Kcal/ml)
Lipid 20% = 2 Kcal/mo, 8.5% amino acid = .085
g/ml
(Mazzaferro, 2004)

PPN Products
10% Aminosyn: $13.64/500 ml
amino acid only, need to dilute in
maintenace fluids to give peripherally,
need to add CHO source and dilute
Procalamine: amino acids, some
electrolytes and glycerol, hard to find (old
price ~ $40/L)
Freeamine: amino acids and electrolytes
(NOT BES, low NaCl), can add 50%
dextrose to make a 5% solution
(Mensach, IVECCS, 2005. Matthews, Vet Clinics, 1998)

PPN Recipe
Remove 100 ml from 1 L bag of Normosol M
Add 100 cc 50% dextrose to yield ~ 5%
dextrose in Normosol M
Remove 330 ml of fluid from above
Add 330 ml of amino acid solution to above
(e.g. Travasol)
Final solution is:
3.3% amino acid (33g protein)
50 mEq/L Cl
3.3% dextrose (33g dextrose)
20 mEq/L PO4
30 mEq/L KCl 5 mEq/L Mg
45 mEq/L Na 650 mOsm/L
(Matthews, Vet Clinics, 1998)

References
1. Vet Clinics of North America Advances in
Fluid Therapy, May 1998
a. Distribution of Body Water and General
Approach to the Patient. Greco, p. 473.
b. Various Types of Parenteral Fluids and
Their Indicators. Matthews, p. 483.
c. Fluid Therapy in Shock. Mandell and King,
p. 623.
d. Hyponatremia. DiBartola, p. 515.
e. Hypernatremia. Marks and Taboada, p.
533.

References
f. Clinical Disorders of Potassium
Homeostasis. Phillips and Polzin, p. 545.
g. Hypercalcemia and Hypermagnesimia.
Martin, p. 565.
h. Hypocalcemia and Hypomagnesimia.
Dhupa and Proulx, p. 587.
2. Proceedings 11th IVECCS Symposium,
Sept. 2005.
a. Fluid Therapy: Options and Rational
Selection. Mensach, p. 389.

References
b. Update on Synthetic and Natural Colloids.
Chan, p. 395.
c. Designer Fluid Therapy. Wall, p. 405.
d. Clinical Use of 25% Human Serum Albumin
in Veterinary Patients. Mathews, p. 411.
e. Clinical Use of Serum Lactate. Hughes, p.
173.
3. Multidisciplinary Systems Review,
Proceedings 10th IVECCS Symposium,
September 8, 2004.
a. Nutritional Requirements of the Critically Ill
Patient. Mazzaferro, p. 1.