fluid-therapy

# Fluid Therapy ## Overview Systematic fluid assessment, calculation methodology, and species-specific resuscitation protocols. Includes dehydration severity estimation, crystalloid vs. colloid selection, shock dose rates, maintenance formulas, and electrolyte correction guidelines. ## When to Use - User assesses dehydration severity or plans fluid therapy - User needs shock dose calculation, maintenance rate, or electrolyte supplementation - Keywords: fluids, crystalloid, colloid, LRS, Normosol, saline, dehydration, shock dose, maintenance rate, bolus, hypovolemia, potassium, electrolytes ## Dehydration Assessment **Physical Examination Markers**: - **Skin Turgor**: Pinch dorsal neck skin; normal returns immediately, mild dehydration (5%) returns slowly (<2 sec), moderate (7-8%) returns over 2+ seconds, severe (10%+) remains tented - **Mucous Membrane Color**: Normal pink, pale (early shock/severe dehydration), injected (fever, pain, inflammation) - **Capillary Refill Time (CRT)**: Normal <2 seconds (dogs/cats); 2-3 seconds = mild dehydration/early shock; >3 seconds = moderate-severe shock - **Eye Globe Position**: Normal in orbit, sunken (>5% dehydration), bulging (increased posterior pressure, less common) **Dehydration Severity**: | Severity | % Dehydration | Clinical Signs | Fluid Rate | |---|---|---|---| | Mild | 5% | Minimal mucous membrane dryness, slight skin turgor delay | Maintenance + deficit over 24h | | Moderate | 7-8% | Dry mucous membranes, skin tenting, CRT 2-3 sec | Bolus + maintenance | | Severe | 10%+ | Very dry mucous membranes, significant skin tenting, CRT >3 sec, lethargy, weak pulses | Rapid shock dose | ## Crystalloid vs. Colloid Selection ### Crystalloids (First-Line) **Composition**: - **Balanced Solutions** (preferred): Lactated Ringer's (LRS), Normosol-R, PlasmaLyte A—electrolyte composition closer to plasma; less hyperchloremia - **Saline Solutions**: 0.9% NaCl (normal saline), 3% NaCl (hypertonic) **Advantages**: Inexpensive, readily available, redistribution to interstitium allows tissue hydration, less infection risk **Disadvantages**: Rapid redistribution (only 25% remains intravascular at 1 hour), third-spacing risk, hyperchloremia if large volumes **Dosing**: Maintenance + deficit replacement + ongoing loss ### Colloids (Adjunctive) **Synthetic**: Dextran 70/40 (polysaccharide, 6-8 hour duration), hetastarch (starch-based, 12-24 hour duration), Gelatin **Natural**: Fresh frozen plasma (FFP, contains clotting factors), fresh whole blood (RBCs + plasma) **Indications**: Hypoproteinemia (<4.5 g/dL), ongoing protein losses, failed crystalloid resuscitation, bleeding **Dosing**: Hetastarch 10-20 mL/kg IV over 15-30 min; dextran 5-10 mL/kg; max 40 mL/kg/day total **Considerations**: Expense, short shelf-life (hetastarch), coagulation effects (dextran, high-dose hetastarch), infection risk lower than colloids ## Resuscitation (Hypovolemic Shock) **Modern approach: Incremental boluses, not full shock-dose infusion.** Historical "shock rates" (dog 90 mL/kg, cat 60 mL/kg total crystalloid volume) represent the approximate blood volume and are useful as a ceiling, but current RECOVER/critical care guidelines recommend smaller boluses with reassessment between each. **Dogs**: 10-20 mL/kg IV bolus over 15-20 minutes, reassess, repeat up to 3-4 times as needed. Total resuscitation volume should not exceed 80-90 mL/kg without reassessing for ongoing losses or considering colloids/blood products. **Cats**: 5-10 mL/kg IV bolus over 15-20 minutes, reassess. Cats are more sensitive to volume overload; total should not exceed 50-60 mL/kg without reassessment. Monitor for pulmonary edema. **Horses**: 10-20 mL/kg IV bolus, reassess. Large volumes required due to body size; hypertonic saline (4-5 mL/kg) can be used as a bridge. **Reassessment targets between boluses**: Heart rate trending down, CRT improving toward <2 sec, mucous membrane color improving, urine output >1 mL/kg/hr, lactate decreasing. **Example (10 kg dog, hemorrhagic shock)**: - Initial bolus: 10 kg x 15 mL/kg = 150 mL LRS IV over 15 min - Reassess: HR still elevated, CRT still >2 sec → repeat bolus - Second bolus: 150 mL LRS IV over 15 min - Reassess: HR normalizing, CRT <2 sec → transition to deficit replacement rate ## Maintenance Calculation (Non-Dehydrated Patient) **Formula (dogs/cats)** — two common methods that diverge for small patients, so pick one and titrate: - **Per-kg**: ~50 mL/kg/day (range 40-60). 10 kg → ~500 mL/day (~20 mL/hr); 30 kg → ~1,500 mL/day. - **Allometric (Merck standard, ~2-70 kg)**: **(30 × BW_kg) + 70 = mL/day**, which scales down as weight rises. 10 kg → 370 mL/day (~15 mL/hr); 30 kg → ~970 mL/day (~40 mL/hr). The per-kg method overestimates for large dogs; the allometric method is generally preferred as body weight increases. Titrate to hydration, urine output, and ins/outs rather than the formula alone. **Alternative formula** (simpler): 1-2 mL/kg/hour maintenance - 10 kg dog: 10-20 mL/hr - 30 kg dog: 30-60 mL/hr **Cats**: Generally lower requirement; 1-2 mL/kg/hour, or 30-50 mL/day for average adult **Adjustments**: Increase for fever (12.5% per degree Celsius above 38.3°C), hyperventilation, drainage losses (wound, fistula, diarrhea), polyuria ## Deficit Replacement **Formula**: Percent dehydration × body weight = volume to replace - Example: 8% dehydration in 20 kg dog = 0.08 × 20 kg = 1.6 liters **Replacement timeline**: - **Acute/severe dehydration** (dog with shock): Replace 50% of deficit in first 6 hours (via shock boluses), remainder over 24 hours - **Moderate dehydration** (stable patient): Replace deficit evenly over 24 hours - **Mild dehydration** (maintenance only): May not require separate replacement; address ongoing losses **Calculation**: Deficit mL/24 hours ÷ 24 hours = additional mL/hr beyond maintenance ## Ongoing Loss Replacement **Gastrointestinal Losses** (vomiting, diarrhea): - Estimate volume: small bowel diarrhea >200 mL/day, vomiting varies; weigh bandages/pads - Electrolyte composition: High chloride, potassium (especially with diarrhea) - Replacement: Replace estimated loss mL-for-mL; add appropriate electrolytes **Hemorrhage**: - Crystalloid bolus: 3:1 ratio (3 mL crystalloid for each 1 mL blood loss) - Ongoing: Assess packed cell volume (PCV) trend; transfusion if PCV <15-20% **Insensible Losses** (respiration, sweating): ~10-20 mL/kg/day; included in maintenance calculation ## Electrolyte Correction ### Potassium (K+) Supplementation **Indications**: K+ <3.5 mEq/L (hypokalemia), especially with cardiac arrhythmias, weakness, polyuria **Supplementation Scale** (KCl *added* to crystalloid — the Scott/DiBartola sliding scale; these are concentrations, not infusion rates): | Serum K+ (mEq/L) | KCl to add per liter | Max fluid rate | |---|---|---| | 3.6-5.0 | 20 mEq/L | 25 mL/kg/hr | | 3.1-3.5 | 28-30 mEq/L | 18 mL/kg/hr | | 2.6-3.0 | 40 mEq/L | 12 mL/kg/hr | | 2.1-2.5 | 60 mEq/L | 8 mL/kg/hr | | <2.0 | 80 mEq/L | 6 mL/kg/hr | Each row pairs a concentration with a maximum fluid rate so that potassium delivery stays at or below the ceiling (concentration × max rate ÷ 1000 ≈ 0.5 mEq/kg/hr). **⚠️ Maximum infusion rate — hard limit**: Do **NOT** exceed **0.5 mEq/kg/hr** of potassium, regardless of serum K+ or concentration. Faster rates risk fatal hyperkalemic cardiac arrest; use ECG monitoring at or near this ceiling. **Max Concentration**: 40 mEq/L (peripheral IV — vein irritation above this); 60-80 mEq/L via central line only. **Monitoring**: Recheck K+ after 4-6 hours; goal 3.5-4.5 mEq/L. Values verified in `docs/clinical-review-2026.md`. **Example (20 kg dog, K+ 2.4 mEq/L)**: - Band 2.1-2.5 → add 60 mEq KCl per liter of fluids; cap the fluid rate at 8 mL/kg/hr. - Check: 8 mL/kg/hr × 60 mEq/L ÷ 1000 = 0.48 mEq/kg/hr — within the 0.5 mEq/kg/hr ceiling. ✓ ### Sodium (Na+) Correction **Hypernatremia (Na+ >155 mEq/L)**: Rapid correction risks cerebral edema; correct slowly over 48 hours - Free water replacement: D5W or 0.45% NaCl - Formula: (serum Na - 150) × 0.6 × BW (kg) = mEq Na to remove **Hyponatremia (Na+ <125 mEq/L)**: Symptomatic (<120) requires hypertonic saline (3% NaCl) - Sodium deficit: (target Na − current Na) × 0.6 × BW (kg) = **mEq of Na needed**. 3% NaCl provides ~0.51 mEq Na/mL, so divide the mEq by ~0.5 to get mL of 3% NaCl. - For acute symptomatic hyponatremia, give 3-5 mL/kg of 3% NaCl over 15-20 min, then recheck. - **Correction limit**: raise serum Na by **no more than ~10-12 mEq/L per 24 hours** (chronic hyponatremia: slower). Correcting faster than this risks osmotic demyelination syndrome. ## Acid-Base Considerations **Metabolic Acidosis** (common in shock, sepsis): - Fluid resuscitation (crystalloid) improves perfusion → lactate clearance - Sodium bicarbonate rarely indicated acutely (empirical dosing risky); recheck ABG after resuscitation - If needed: mEq bicarb = 0.3 × (desired HCO3 - actual HCO3) × BW (kg); administer slowly IV **Metabolic Alkalosis** (contraction alkalosis post-vomiting): - Chloride-containing fluids (LRS, 0.9% NaCl) preferred - Address underlying cause (anti-emetics, electrolyte correction) ## Monitoring Parameters **Reassessment intervals**: q15 min during resuscitation, q30-60 min post-stabilization, q4-6h stable patients - CRT, mucous membranes, perfusion - Urine output (goal >1 mL/kg/hr, cats >0.5 mL/kg/hr) - BUN/creatinine (assess renal perfusion) - Electrolytes (especially K+ during supplementation) - PCV (if hemorrhage/transfusion consideration) ## Species-Specific Considerations **Dogs**: Tolerate larger boluses (10-20 mL/kg increments); lower risk of volume overload than cats; total resuscitation ceiling ~80-90 mL/kg **Cats**: More sensitive to volume overload; use 5-10 mL/kg boluses; monitor closely for pulmonary edema; total resuscitation ceiling ~50-60 mL/kg **Rabbits**: Rapid dehydration common; slow crystalloid infusion preferred (interstitial space limited); glucose supplementation often needed **Horses**: Large volumes; central line access preferred; risk of dependent edema with prolonged standing; monitor carefully ## Limitations - **Dehydration assessment**: Subjective; CRT/skin turgor affected by age, obesity, skin condition, ambient temperature - **Shock dosing**: Empirical dosing; individual variation significant; reassessment critical (ongoing losses, bleeding, fluid sequestration) - **Electrolyte repletion**: Risk of overcorrection (especially Na+, K+); serial lab assessment essential, not single calculation - **Crystalloid distribution**: 75% shifts to interstitium; third-spacing common in peritonitis, sepsis; colloid consideration in severe cases - **Maintenance calculation**: Variation based on age, metabolism, disease state; formulas are approximations - **Referral**: Complex cases (multiple electrolyte disturbances, ongoing hemorrhage, sepsis) warrant internist/anesthesiology consultation