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Proceedings of the Southern European Veterinary Conference - SEVC Sep. 29-Oct. 2, 2011, Barcelona, Spain

Next SEVC Conference:

Oct. 18-21, 2012 - Barcelona, Spain

Reprinted in the IVIS website with the permission of the SEVC - AVEPA

Published in IVIS with the permission of SEVC

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INTRODUCTION TO FLUID THERAPY Stephen P. DiBartola, DV , DACVI Colle!e o" Veterinar# e$i%ine Ohio State Uni&er'it# Col()*(', OH USA Fluid therapy is supportive. The underlying disease process that caused the fluid, electrolyte, and acid-base disturbances must be diagnosed and treated appropriately. In formulating a fluid therapy plan, 6 questions should be considered: 1. Is fluid therapy indicated? 2. What type of fluid should be given? 3. By what route should the fluid be given? 4. How rapidly should the fluid be given? . How !uch fluid should be given? ". When should fluid therapy be discontinued? 1. Is fluid therapy indicated? The hydration status of the animal is estimated by careful evaluation of the history, physical examination findings, and the results of a fe simple laboratory tests. !ormally, fluid input consists of ater consumed in food, ater that is drun", and ater produced metabolically in the body. #aintenance ater and electrolyte needs parallel caloric expenditure, and normal daily losses of ater and electrolytes include respiratory, fecal, and urinary losses. In disease states, decreased fluid inta"e results from anorexia, and increased fluid loss may occur by urinary $e.g., polyuria% and gastrointestinal $e.g., vomiting, diarrhea% routes. Third-space loss of fluid occurs hen effective circulating volume is decreased, but the fluid lost remains in the body. The time period over hich fluid losses have occurred and an estimate of their magnitude should be determined. &hysical findings associated ith fluid losses of '( to )'( of body eight vary from no clinically detectable changes $'(% to signs of hypovolemic shoc" and impending death $)'(%. The hydration deficit is estimated by evaluating s"in turgor, moistness of the mucous membranes, position of the eyes in their orbits, heart rate, character of peripheral pulses, capillary refill time, and extent of peripheral venous distention $i.e., inspection of *ugular veins%. + decrease in the interstitial compartment volume leads to decreased s"in turgor and dryness of the mucous membranes. + decrease in plasma volume leads to tachycardia, alterations in peripheral pulses, and collapse of peripheral veins. ,hen these cardiovascular signs are present, the patient is in shoc" and should be resuscitated promptly before correction of the hydration deficit. Thus, a crude clinical estimate of hydration status and the patient-s response to fluid administration become important tools in evaluating the extent of dehydration and planning fluid therapy. The urinary bladder should be small in a dehydrated animal ith normal renal function. In the absence of urinary obstruction, a large bladder in a severely dehydrated patient indicates failure of the normal renal concentrating mechanism. .ody eight recorded on a serial basis traditionally has been considered a good indicator of hydration status, especially hen fluid loss has been acute and previous body eight has been recorded $i.e., ) "g loss of body eight equals a ) / fluid deficit%. In one study, ho ever, clinician estimates of hydration in dogs and cats admitted to a veterinary teaching hospital intensive care unit did not reliably predict changes in eight after 01 to 12 hours of fluid therapy. In chronically ill animals, loss of eight also includes loss of muscle mass. +norexic animals have been estimated to lose 3.) to 3.4 "g of body eight per day per )333 "cal energy requirement. +nother factor that must be considered in evaluating body eight is the possibility of third-space loss. Fluid lost into a third space does not decrease body eight. &ac"ed cell volume

Proceedings of the Southern European Veterinary Conference & Congreso Nacional AVEPA, 2011 - Barcelona, Spain

Published in IVIS with the permission of SEVC

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$&56%, total plasma protein concentration $T&&%, and urine specific gravity $789% are simple laboratory tests that aid in the evaluation of hydration. These results should be obtained before initiating fluid therapy. 2. What Type of Fluid Should Be Given? The composition of a balanced fluid $e.g., lactated :inger-s solution% resembles that of extracellular fluid $;5F% hereas that of an unbalanced solution $e.g., normal saline% does not. Fluid preparations may be further classified as crystalloids or colloids. 5rystalloids $e.g., '( dextrose, 3.<( saline, lactated :inger-s solution% are solutions containing electrolyte and non-electrolyte solutes capable of entering all body fluid compartments. 5olloids are large-molecular- eight substances that normally are restricted to the plasma compartment and include plasma, dextrans, and hydroxyethyl starch $hetastarch%. 5rystalloid solutions expand the plasma compartment ith equal effectiveness, but 0.' to 4.3 times as much crystalloid solution must be given $compared ith a colloid solution% because the crystalloid is distributed to other sites $e.g., interstitial compartment, intracellular compartment%. 5rystalloid solutions also can be classified as replace!ent or !aintenance solutions. The composition of replacement solutions resembles that of ;5F hereas maintenance solutions contain less sodium $13 to 63 m;q=/% and more potassium $)' to 43 m;q=/% than do replacement fluids. #ost animals that require fluid therapy can be managed ith a limited number of crystalloid and additive solutions. The most useful crystalloid solutions for routine use are a balanced replacement solution $e.g., lactated :inger-s solution, !ormosol-:, &lasma-/yte )12%, 3.<( saline, and '( dextrose in ater. 8upplementation of crystalloid solutions ith >5l may be necessary hen body fluid losses have included large amounts of potassium. The choice of fluid to administer is dependent on the nature of the disease process and the composition of the fluid lost. The patient-s acid-base and electrolyte disturbances should be considered hen choosing a fluid, and losses should be replaced ith a fluid similar in volume and electrolyte composition to the fluid that has been lost. If clinical assessment of the patient suggests a fluid-responsive type of shoc", the resuscitation phase of fluid therapy should be instituted. If clinical signs of hypovolemia are not present, the hydration deficit and maintenance needs may be combined and administered during the next 01 hours. 3. By What Route Should Fluids Be Given? The route of fluid therapy depends on the nature of the clinical disorder, its severity, and its duration. The intravenous route is preferred hen the patient is very ill, hen fluid loss is severe, or hen fluid loss is acute. 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 43 m;q=/ ithout irritation. +pproximately )3 m/="g or '3 to 033 m/ of fluid may be administered per site. . !o" Rapidly #ay Fluids Be Given? The rate of fluid administration is dictated by the magnitude and rapidity of the fluid loss. The patient ith fluid-responsive shoc" syndrome requires aggressive fluid administration. Fluid administration rates may vary, depending on the type of fluid that has been chosen. ?ne approach is to calculate a @shoc" fluid doseA and administer it as rapidly as possible in divided aliquots until a stable and sustainable cardiovascular endpoint has been achieved. 5linical evaluation of the patient should occur after administration of each aliquot using a @titrate to effectA approach. The shoc" dosage of isotonic crystalloids is 23 to <3 m/="g for dogs and 13 to 63 m/="g for cats. 5ontemporary losses also must be considered hen ad*usting the rate of fluid administration. 8evere ongoing losses $e.g., vomiting and diarrhea in a patient ith acute gastroenteritis% may necessitate rapid administration to "eep pace ith contemporary fluid loss. ,hen fluids are given rapidly, cardiovascular and renal function should be monitored. It usually is not necessary or desirable to replace the hydration deficit rapidly in chronic disease states. Instead, the hydration deficit may be calculated, the daily maintenance requirement of fluid added to this amount, and the total volume administered over 01 hours. ?ngoing or contemporary losses also must be ta"en into consideration hen estimating the patient-s fluid requirements for a 01-hour period.

Proceedings of the Southern European Veterinary Conference & Congreso Nacional AVEPA, 2011 - Barcelona, Spain

Published in IVIS with the permission of SEVC

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$. !o" #uch Fluid Should Be Given? The purpose of fluid therapy is to increase tissue perfusion, repair fluid deficits, supply daily fluid needs, and replace ongoing losses. The initial assessment of hydration determines the volume of fluid needed to correct the hydration deficit $replace!ent re#uire!ent%. The hydration deficit is calculated as the percentage dehydration $estimated by physical examination% times the patient-s body eight in "ilograms. The resultant value is the fluid deficit in liters. Buring the rehydration phase of therapy, this volume is administered over 01 hours in con*unction ith maintenance fluid requirements and replacement of ongoing or contemporary losses. 5oincident ith or after replacement of the animal-s hydration deficit, the !aintenance re#uire!ent must be administered. The maintenance fluid requirement is the volume needed each day to "eep the animal in balance $i.e., no net change in body ater%. The maintenance fluid requirement for dogs and cats can be determined from reference charts that use formulas based on energy expenditure to calculate accurate daily fluid requirements. +lthough estimates of 13 to 63 m/="g=day frequently are used to calculate maintenance fluid requirements, such estimates are only accurate for some animals. 5ats, very small dogs, and very large dogs are not ell served by the use of such estimates, and these patients may benefit from more accurate assessment of their fluid requirements. +pproximately t o-thirds of the maintenance requirement represents sensible $i.e., easy to measure% losses of fluid $i.e., urine output%, and one-third represents insensible $i.e., difficult to measure% losses $i.e., primarily fecal and respiratory ater loss%. In addition to the hydration deficit $replacement requirement% and maintenance requirement, conte!porary $ongoing% losses must be considered. These are not al ays easily determined but can be very important. ?ngoing losses $including those caused by vomiting, diarrhea, polyuria, large ounds, drains, peritoneal or pleural losses, panting, fever, and blood loss% should be estimated and carefully replaced along ith the maintenance volume of fluid. %. When should fluid therapy &e discontinued? :epeated assessment of the patient by observation of clinical signs and determinations of body eight, urine output, &56, T&&, and 789 is necessary to ma"e appropriate ad*ustments in fluid therapy. The animal-s urine output should be observed carefully after fluid therapy has begun. #easurement of central venous pressure $56&C normal, 3-4 cm D 0?% ith a *ugular catheter positioned at the level of the right atrium allo s the cardiovascular response to fluid administration to be monitored. 56& increases from belo normal into the normal range hen fluids are administered to a dehydrated animal. + progressive increase in 56& above normal during fluid therapy is an indication to decrease the rate of fluid administration or to stop fluid therapy temporarily. Ideally, fluid therapy is discontinued hen hydration is restored and the animal can maintain fluid balance on its o n by eating and drin"ing. +s the animal recovers, fluid therapy usually is tapered by decreasing the volume of fluid administered by 0'( to '3( per day. REFERENCES 5ornelius /#: Fluid therapy in small animal practice. & '! (et )ed 'ssoc )E6:))3, )<23. 5ornelius /#, Finco B:, and 5ulver BD: &hysiologic effects of rapid infusion of :ingerFs lactate solution into dogs. '! & (et *es 4<:))2', )<E2. 5unha #9, Freitas 95, 5arregaro +., et al. :enal and cardiorespiratory effects of treatment ith lactated :ingerFs solution or physiologic saline $3.<( !a5l% solution in cats ith experimentally-induced urethral obstruction. '! & (et *es E):213-216, 03)3. Dansen . and BeFrancesco T: :elationship bet een hydration estimate and body eight change after fluid therapy in critically ill dogs and cats. & (et +!erg ,rit ,are )0:04', 0330. :ose :G: 8ome physiological and biochemical effects of the intravenous administration of five different electrolyte solutions in the dog. & (et -har!acol .her 0:0E<, )<E<.

Proceedings of the Southern European Veterinary Conference & Congreso Nacional AVEPA, 2011 - Barcelona, Spain