This section shows how to give sub-cutaneous fluids using the syringe method, and includes photographs. There is also information on the Clothes Peg (Clothes Pin) trick, since a lot of people are asking about this lately; whilst the More Sub-Q Tips section includes other tips and hints to help make the sub-Qs process easier.

1.   CAUTION

Sub-Qs are not always appropriate and in fact in certain circumstances can do more harm than good. Do NOT give sub-cutaneous fluids to your cat if:

1. your vet has refused to agree to the procedure on medical grounds; or

2. your cat has a heart condition (fluid therapy may still be possible but your vet must decide if it is appropriate for your cat, and determine the amounts and frequencies to be administered); or 

3. fluids from the previous session have not yet been absorbed; or

4. your cat is over-hydrated. This may be obvious, or your cat may feel "squishy", the way water in a plastic bag feels  - squishiness sometimes happens if a little air gets in with the fluids, and is not normally a problem, but if it happens consistently, your cat may need less fluid. Other symptoms of overhydration may include sudden weight gain, coughing and nasal discharge. See Symptoms for more information. Overhydration may be associated with a heart condition, but contrary to what some vets claim it can still happen in a cat with a perfectly normal heart. It is a good idea to weigh your cat regularly, to check for sudden or continous weight gain which may give early warning of a problem; or

5. Think carefully about giving sub-Qs if your cat has a creatinine level of below 300 (US: 3.5) - it can be better to wait longer if possible, although some cats such as Thomas do in fact need fluids at this level.  

6. If your cat has high bloodwork levels (creatinine over 7), s/he might benefit more from intravenous fluids (IV or a drip) initially, with sub-Qs provided once s/he returns home as needed. Speak to your vet about this;

7. My vet agreed to us doing fluids in part because she felt Thomas would not find them too distressing. You and your vet do need to take your cat's personality into account in deciding whether to go this route; but do not necessarily assume your cat cannot cope, many cats who ordinarily hate medication of any kind tolerate sub-Qs because they make them feel so much better. I would suggest trying them for a few weeks at least.  

8. Many cats appear happier (more active and alert, with a better appetite) after sub-Qs. However, some may become lethargic for an hour or so afterwards. This is probably nothing to worry about, but if it happens frequently it may be that your cat is not processing the fluid very well, so I would ask your vet to check your cat for possible heart problems or fluid retention.

2.  Fluid Preparation

In order to avoid any possible problems with infection or contamination, never use a bag of fluids if the contents look cloudy. Often the bag itself will look a bit misty, particularly if you have just removed it from the fridge, but if the contents themselves look cloudy, that is a red flag.

In addition, a bag of fluids should not be used for longer than ten days. If you are giving 100ml of fluid every day, this is not a problem, but if you are only giving fluids every other day or small amounts at one time, this means you will have to discard a 1 litre bag before you have finished it. It is possible to buy 500ml bags of fluid, but these tend to work out more expensive than buying 1 litre bags and discarding what you don't use. See Obtaining Supplies Cheaply for fluid purchasing options.

Fluids may be kept in the fridge and removed shortly before use, but if you are going to use up a bag of fluids within ten days of opening it, it is usually not necessary to refrigerate it. We stopped refrigerating our fluids and had no problems.

When used straight from the fridge or even at room temperature, some cats find the fluids uncomfortable and may twitch, so you should warm them before use: place the bag of fluids in a bowl full of hot water, ensuring that the entrance to the bag (where the marker is; this is blue on the bag of fluid in the photos below) is not immersed, and leave to warm for ten minutes. Alternatively, you could use a heatpad to warm the fluids. Make sure the fluids are not so hot that they will burn your cat! Warming fluids in the microwave is not recommended because it is hard to get the right temperature so you may find the fluids are too hot. Some cats prefer the fluids at room temperature so experiment to see what works best for you both.

3.  Needles

The type of needle used can make a tremendous difference to your and your cat's comfort and stress levels. The size is to some extent a matter of choice: as long as you use a needle between 18 and 23, you should have no problems (with needles, the higher the needle, the finer - smaller - the needle is). If you choose a needle below size 18, it can be rather big and uncomfortable for the cat (size 16, for example, is often used on goats and sheep).

What is most important is to use needles intended for humans made by Terumo. These needles are extremely sharp, plus the smaller gauge needles (from size 20 upwards) in the human range are ultra thin wall (UTW), meaning the diameter of the inside bore is larger than another manufacturer's needle of equivalent size, allowing greater flow rate (if you visit the above link, click on "Download Neolus needles pdf file" at the bottom left of the page to see exactly how they work). If you haven't yet used Terumo needles, give them a try, preferably the human type rather than the veterinary type if you are using size 20 or above because they have the ultra thin wall. Most Feline CRF Information listmembers use size 19 or 20 because these give a balance between size of needle and speed of fluid flow. You can obtain details of mail order suppliers in Obtaining Supplies Cheaply, but you can expect to pay around US$5-6 for 100 needles.

Some people find it can be hard to remove the covers off Terumo needles. There are various ways to do it, but one way that seems to work is to attach the needle to the IV tubing, then twist and tug the cover quickly. Alternatively you can rock the cap to and fro to loosen it, then pull up quickly.

Some CRF List members have started freezing needles before using them. This was because of a study (Denkler K (2001) Pain associated with injection using frozen versus room-temperature needles Journal of the American Medical Association 286 p1578), where a plastic surgeon who froze needles before using them on his (human! - what cat needs plastic surgery?) patients found that 76.6% of the patients found the frozen needles less painful. Freezing the needles doesn't always seem to make a difference for cats, but it might be worth a try. If you decide to try this, do not freeze the needles for longer than a few days in case it adversely affects the sterile packaging.

David Jacobson's Website has information on the various flow rates of different needle sizes - if your cat hates fluids, you need to decide if it is the actual sticking that bothers him/her (in which case opt for a size 20 or above), or if it's the length of time it takes (in which case opt for a size 18 or 19 which will get the job done quicker).

4.  The Syringe Method

Although the use of a giving set, whereby the fluids drip out of a bag rather like into human patients on an IV drip, is more common in the USA, we used the syringe method to give Thomas his fluids. This has the advantages of speed plus precision regarding the amount administered. The main disadvantage of this method is that it can be difficult for one person to do alone if the cat is the type to fidget. If you wish to learn how to give fluids using a giving set, please visit How to Give Sub-Cutaneous Fluids: Giving Set Method for information on how to do this.

Below we show how we gave Thomas his fluids. As you can see, whilst it was not exactly the highlight of his day, it certainly did not distress him in any way. Some CRF cats like the fluids so much that they come and remind their humans if they are a little late giving them!

This is a small needle used for drawing up fluids: we used a Terumo size 21.  

This is a syringe: we always used 20ml syringes because that is what we were originally given by our vet and we got used to them; you might prefer to use larger ones, particularly if you are giving fluids alone, though the bigger the syringe, the harder they are to squeeze. Thomas received 100ml of fluid at each session so we used five of these altogether.

Attach the opposite end of the needle to the end of the syringe. 

Take the protective cover off the end of the Terumo needle so the needle is exposed. 

Take the bag of fluids and find the entrance with the blue marker. Insert the needle into the clear cellophane as far as it will go (you only need to push gently).

Hold the fluids upright and gently pull on the end of the syringe, gradually drawing the fluids up into the syringe. Try not to pull up air - keeping the fluids upright can minimise this.

When the syringe is full, remove the needle and lay the syringe on its side on a clean cloth, ensuring the end where the needle was attached is not touching the cloth.

Continue drawing up fluids in this way (it is fine to use the same Terumo  needle attached to each syringe) into syringes until you have as many syringes as you require. 

Lay all the syringes on a clean cloth where you can reach them easily when you have your cat on your knee. Put the bag of fluid to one side until you are able to put it back in the fridge if that is where you store it - the valve on the bag of fluids is one-way, so you do not need to worry about the fluids spilling or leaking.

Next, take another needle: this one is a butterfly needle (also known as a winged infusion set), a needle with a narrow tube attached. We used size 23, which is a very fine needle. 

Attach the end of the butterfly to the end of one of the syringes. Take the cap off the end of the butterfly needle. Squeeze gently so the fluid begins to flow and clears the air out of the needle.

Place your cat comfortably on your knee. Pinch some of your cat's skin to form a tent, or pouch. There is no need to apply alcohol to the cat's skin first (Washington State University explains why this isn't necessary unless the cat has a poor immune system, e.g. also has cancer). ).

Hold the needle so the bottom end is the longer end - the needle looked at sideways will look like this:  ______\ or this:  l____ . Holding the needle parallel to your cat's back, insert the needle smoothly into the tent you have formed. 

It can be helpful not only to move the needle towards the tent, but also to raise the skin slightly to meet the needle. Ensure you have not pushed the needle through the other end of the tent - the fluid will leak if so. 

Hold your cat with one hand, and squeeze steadily on the syringe with the other. There will be slight resistance as you squeeze on the syringe, and if it seems to going in too easily, the chances are the needle is sticking out the other side of the tent. 

Your cat may flinch slightly when the fluids first start going in - this may be because the fluids are too warm or too cold for the cat's liking, or as my vet says, the sensation can be a little bit of a shock to start with. Thomas never flinched at the needle  but occasionally did at the first squeeze of the syringe. As you can see, he did not find sub-Qs distressing.

Steadily squeeze all the fluid contents of the syringe into your cat. If there  is some air at the end of the syringe, stop squeezing before you reach the air so that you do not inject it into your cat.

When you have finished, remove the needle and pinch or massage the injection area for a minute or so - this will minimise the possibility of fluids leaking. Occasionally you will see a little blood when you withdraw the needle - this just means that you have nicked a small blood vessel and is usually nothing to worry about.

Put the sub-Q fluid back in your fridge or storage area until the next session. Replace the syringes in their containers - it is safe to use them again. Put the lids back on the needles and do not use them again - you must be careful about disposing of needles, which are clinical waste, so the safest thing is to keep them somewhere safe away from children and your pets and ask your vet to dispose of them permanently for you.  

5. The Clothes Peg (Clothes Pin) Trick

If your cat wriggles or gets stressed during sub-Qs, you can try the clothes peg (clothes pin) trick: this is a form of acupressure recommended by an acupuncturist vet. Below, Joan's Sassy models this trick. As you can see, Sassy is not a particularly placid cat, but this method enables Joan to give Sassy fluids successfully and with much less stress for either of them. As usual, please check with your vet before trying this.

Be sure to "clip the kitty" when he or she is calm, and before you begin the sub-Qs. It won't work once the cat is upset and squirming to get away. 

You take standard wooden clothes pegs (clothes pins), and clip the scruff of the cat's neck starting at the back of the skull where the skin is loose. 

You attach three clothes pegs side-by-side to form a "ridge" down the centre of the back of the neck. Some cats might need to have as many as six clothes pegs placed there for it to be effective. It looks just like a "kitty mohawk" when done properly.

This is what it looks like from the side. The clothes pegs can pinch if you don't clip enough skin in the teeth, so make sure you have enough skin in them to create pressure, but not to hurt the cat. Most cats should relax quite a bit within a few minutes - some even lie on their side. The effect is very similar to the way rabbits trance when you flip them on their backs (which I don't recommend for rabbits, by the way). 

Once you've finished the sub-Qs, you can remove the clips, and the cat should be fully alert within a few minutes. 

Some eight years after I first heard about this method, The Winn Feline Foundation reported on a study, Pinch-induced behavioral inhibition ('clipnosis') in domestic cats (2008) Pozza ME, Stella JL, Chappuis-Gagnon AC, Wagner SO, Buffington CA Journal of Feline Medicine & Surgery 10(1) pp82-7 which concluded that "PIBI was useful for gentle restraint in most cats."

6.  Some More Sub-Q Tips

It often helps both you and your cat if you set up a routine and stick to it. Speak to your cat during the procedure and reassure him/her, but don't overdo it or s/he may think s/he is right to be frightened. Try not to be nervous yourself or your cat will sense it; aim to be very matter-of-fact about it all. Tell him/her what you are doing and why - many people find this seems to help. You can also choose a special word or phrase that tells them you are about to give them medication and/or fluids - the cat will soon learn what this means, and will then not be stressed when you approach him/her at other times. Some people have also found Feliway helpful - you can buy Feliway plug-ins and simply leave them on in the room where you usually give fluids. Petguys sells plug-in Feliway for US$23.99 in USA, with refills costing US$11.99.

Some cats can be distracted with a little food during sub-Qs. Even if you prefer not to feed your cat during the procedure, many cats feel hungry after fluids so take the opportunity to offer your cat some food afterwards - we always fed Thomas as his reward for being a good boy. 

Some cats do better if they are restrained during sub-Qs, either by hand or by a cat restraint bag. However, others are more likely to co-operate if they are not restrained and feel they have some kind of control.

Four Flags in USA sells the Cat Sack, for holding your cat while you medicate him/her or administer sub-Qs. It can help with wriggly cats, and most cats do not seem to mind it. It costs between US$27.25 and US$41 plus US$3 shipping.

Drs Foster & Smith sell something similar called the Klaw Kontrol Bag for US$29.99-34.99 plus shipping of US$7.99. 

Dr Shipp's Laboratories sell cat restraint bags in a variety of sizes from US$22.50 plus US$6.50 for shipping.

PetEdge sells grooming bags, which can be used as restraint bags, for US$8.99-10.99.

Some cats feel happier if they are given fluids in a familiar place, whereas others may be more co-operative if the fluids are given in a strange place, perhaps a room they are not normally allowed to enter. Experiment and see what works best. You may also wish to try the clothes peg (clothes pin) trick (see above). Intravenous Fluids and Sub-Cutaneous Fluids also has some information from various sources on how to give sub-Qs.

You do not need to restrict your injections to the neck area, in fact it is better to move around the body in order to minimise the possibility of scar tissue forming. Roughly speaking, you can inject your cat anywhere which would be covered by a saddle (as Sophia models here; scroll to near the end of the page) - experiment a little because some cats have preferences - Thomas much preferred being injected on his right side to his left. Be careful to avoid the spine though. You will find it easier to inject your cat if you form a good tent. 

We have given 120ml in one place without any problems, but if you are giving more at any one time, it is probably worth dividing the fluids in two and giving each half in two separate places on your cat. 

After a little while the pouch of fluid which you have injected will move around the cat's body. It may go down one of the front legs or just hang on the stomach, This is normal and is nothing to worry about, though it is better to avoid injecting in an area where the fluid consistently moves down to a front leg because this can be uncomfortable for the cat.

Occasionally you may hear a "crackling" noise under your cat's skin after giving sub-Qs and/or the cat may seem "squishy". This simply means that a little air has got under the skin (this is known as sub-cutaneous emphysema), and is not usually anything to worry about unless it happens regularly. If it does, I would recommend that you discuss it with your vet because it may mean that your cat is over-hydrated in which case you need to reduce the amount of fluid which you are giving; or you may need to refine your technique so as to allow less air under the skin. See Treatments for more information on overhydration.

If your cat flinches when you insert the needle, it is possible that you hit a muscle. Just withdraw the needle, reassure your cat, and try again in another spot. This only happens very rarely, but if it seems to happen regularly, you may be using a type of fluid (such as saline or Normosol) which stings, in which case you may wish to speak to your vet about changing to another type of fluid.

Occasionally you may see a little blood when you withdraw the needle. This usually means you have simply nicked a small vein, and is not normally anything to worry about. You may also see a bit of fluid leaking out after you remove the needle: again, this is normal. If you pinch or massage the injection area for a minute or so as shown here, this will minimise the possibility of fluids leaking.

At some point you will almost certainly accidentally stab yourself with a needle. This is usually nothing to worry about, it happens to virtually everyone and is not usually cause for concern. However, if you have a compromised immune system or if the area becomes red or sore, seek medical advice.

Most cats feel better after receiving fluids, and are often more active, with a better appetite. If your cat becomes lethargic after receiving fluids, in some cases this may be a sign of over-hydration or heart problems.

See Intravenous Fluids and Sub-Cutaneous Fluids for more tips on giving sub-Qs.

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