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Critical Care

Scientific Proceedings: Companion Animals Programme 1

Fluid Therapy: Theory and cases


Laura J. Ruys, DVM, Spoedkliniek voor Dieren Amsterdam, Weesperzijde 147, 1091 ET Amsterdam, NL
lauraruys@gmail.com

Introduction: frustrating. In dehydrated and hypovolemic patients


The most important organs con- with healthy kidneys, fluid therapy can be very successful,
cerned with body fluids are the kid- and over- and undercorrection may be forgiven. In many
neys. A healthy kidney can regulate critical patients, however, renal function, as well as the
the volume and composition of function of other important organ systems such as heart
body fluids with a finesse envied by and lungs, may be impaired. Trauma patients may suffer
the finest fluid therapist, supported from head trauma and internal hemorrhages. In these
by the most modern clinical labo- cases, and many more, giving adequate fluid therapy is
ratory. In hypovolemia and dehydra- quite a challenge. Fluid therapy is regarded by many as
tion, the most important aim is not so much to treat the major life-saving development of the 20th century. In
abnormalities of plasma composition, unless they are the last decades, diagnostic techniques have come into
extreme, but to restore euvolemia and so the ability of range of the practice laboratory and knowledge about
the kidney to correct further disturbances(1). This physiology has increased. The questions that rise among
phenomenon is for veterinarians both reassuring and veterinarians have remained, however: How much, how

Abstracts European Veterinary Conference Voorjaarsdagen 2008 | 83


Critical Care

1 Scientific Proceedings: Companion Animals Programme

fast and what kind of fluid should I give?. These questions to assess whether the patient is hypovolemic, dehydrated
are very hard to answer before answering two other or both, and whether other diseases are present that
questions: Where are fluids needed and where do given could influence fluid tolerance (kidney disease, heart
fluids go? disease, internal bleedings, lung disease). In hypovolemia,
faster fluid replacement is required than in dehydration.
Distribution of body fluids: After fluid therapy for hypovolemia, an animal can still
For the distribution of body fluids, the following values be dehydrated. Whether an animal becomes dehydrated
are commonly used: or hypovolemic or both, depends on the tonicity of the
fluid that was lost.
60% of the body weight consists of water. Two thirds Tonicity refers to the ability of particles in solution to
of this water is intracellular (including red and white induce water movement (8). The tonicity of fluid that is
blood cells), one third is extracellular. Three quarters of lost, determines the redistribution of the remaining fluid
the extracellular fluid is interstitial fluid, one quarter is in the body and therefore determines which compartment
plasma (intravascular). suffers the greatest losses. Loss of an extracellular fluid
with low tonicity (watery fluids with few solutes), as in
Blood volume: inadequate access to water, concentrates the solutes in
Dog: 8-9% of body weight the remaining body fluids. Through osmosis, water will
Cat: 6-7% of body weight (1,2) shift from the intracellular space to the extracellular
space, until an equilibrium is reached. Both compartments
Hypovolemia is a state of decreased blood volume. will share the losses equally. Loss of extracellular fluid
Severe hypovolemia (when more than 25% of the intra- with higher tonicity, as in diarrhea, gives less osmotic
vascular volume is lost) leads to hypovolemic shock (3,4). stimulus. With no supplementation of water from the
Shock is a condition defined as insufficient perfusion of intracellular space, the loss in the extracellular space will
the tissues, leading to tissue hypoxia, and characterized be more severe than in the first example, and the animal
by an altered mental status, cool extremities, tachycardia is more likely to show signs of hypovolemia. As the
or severe bradycardia, mucous membrane pallor, prolon- tonicity of the fluid that is lost increases toward the
ged or absent capillary refill time (CRT), reduced or ab- normal tonicity of extracellular fluid, the volume deficit
sent peripheral pulses and arterial hypotension. In early of the extracellular compartment becomes progressively
stages of shock and in septic disease, dogs may exhibit more severe. In the case of isotonic losses, as in acute
pounding pulses, bright red mucous membranes and a hemorrhages, the entire loss is borne by the extracellular
rapid CRT (5). Is cats, this stage is not clearly recognized. compartment(8,9).

Dehydration is a condition in which the body contains an Where do fluids go?


insufficient volume of water for normal functioning and The composition of the administered fluid, in conjunction
affects the intracellular and interstitial fluid compart- with the hydrostatic and colloid osmotic pressure in the
ments. Severe dehydration can lead to hypovolemic capillaries and tissues, determines how the fluids are
shock. The percentage of dehydration can be estimated distributed.
based on patient history and the following clinical Crystalloids are solutions with small molecular weight
findings(6,7): particles (ions) that pass capillary membranes freely.
Most commonly used are isotonic crystalloids, such as
< 5%: Not detectable, history of vomiting, diarrhea or normal saline (0.9%) or lactated Ringers. Isotonic
lack of water intake crystalloids exert their effects primarily on the interstitial
and intracellular compartments. Colloids, such as
6-8%: Mild to moderate degree of decreased skin Hemohes or Voluven, contain molecules too large to
turgor. Dry oral mucous membranes freely pass intact capillary membranes. For this reason,
colloids are thought of as intravascular volume replace-
10-12%: Marked degree of decreased skin turgor ment fluids (6). When colloids are used in shock resus-
Eyes sunken in orbits. Dry mucous membranes. citation, it is always in conjunction with crystalloids (3).
Possibly signs of shock
Monitoring:
12-15%: Collapse/ shock During shock resuscitation, the patient has to be moni-
tored carefully. Physical exams have to be performed
Where are fluids needed? frequently to assess whether the desired endpoints are
Before starting an aggressive fluid therapy, it is important reached. The following values can be aimed for:

84 | Abstracts European Veterinary Conference Voorjaarsdagen 2008


Critical Care

Scientific Proceedings: Companion Animals Programme 1

Heart frequency: 60-100 (cat: 160-200)


Mucous membranes: pink, moist

Capillary refill time:1.5 s

Pulse quality: strong, regular


Blood pressure: systolic 100 mmHg, mean > 65 mmHg
Central venous pressure: 4-8 cmH2O
Urine production: > 1ml/kg/h

During long term fluid therapy, the patient has additio-


nally to be monitored for electrolytes, hematocrit (>25%),
albumin (>20 g/l), disappearance of initial clinical signs,
and at least twice a day for breathing pattern, respiration
rate and lung sounds(5).

References:
1. Michell AR, Bywater RJ, Clarke KW, Hall LW, Waterman AE. Regulation
of body fluids. In: Veterinary fluid therapy. Blackwell Scientific
Publications, 1989; 1-19
2. Wellman ML, DiBartola SP, Kohn CW. Applied physiology of body
fluids in dogs and cats. In: DiBartola SP. Fluid, electrolyte and acid-
base disorders in small animal practice. Missouri: Saunders Elsevier,
2006; 3-26.
3. Kirby R. Shock and resuscitation parts I and II. WSAVA-FECAVA-HVMS
World Congress 2004, Scientific Proceedings; 228-236.
4. Muir W. Trauma, physiology, Pathophysiology and clinical
implications. J Vet Emerg Crit Care 2006; 16(4) 253-263.
5. Kirby R, Rudloff E. The critical need for colloids: Maintaining fluid
balance. The Compendium 1997; 705-714.
6. DiBartola SP, Bateman S. Introduction to fluid therapy. In: DiBartola
SP. Fluid, electrolyte and acid-base disorders in small animal practice.
Missouri: Saunders Elsevier, 2006; 325-344.
7. Plunkett SJ. In: Emergency procedures for the small animal clinician.
Appendices. Saunders, 2007; 475
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2007 Mar;29(3):148-160.
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hyponatremia. In: DiBartola SP. Fluid, electrolyte and acid-base
disorders in small animal practice. Missouri: Saunders Elsevier, 2006;
47-79.

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