TANYA'S

COMPREHENSIVE GUIDE TO

FELINE CHRONIC KIDNEY DISEASE

 
 

ALL ABOUT SUBCUTANEOUS FLUIDS (SUB-Qs)

 

ON THIS PAGE:


What Are Sub-Qs?


Why We Use Sub-Qs


When to Use Sub-Qs


How Much to Give


If Your Vet Recommends Large Amounts of Fluid


How Often to Give


Will I Always Have to Give Them?


Ways of Giving Sub-Qs: Giving Set, Syringe, or Implanted Catheter/Skin Button


Implanted Catheter or Skin Button


Coping with Giving Them


When Not to Give Subcutaneous Fluids


 

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FLUID THERAPY


Intravenous Fluids


Subcutaneous Fluids


Tips on Giving Subcutaneous Fluids


How to Give Subcutaneous Fluids with a Giving Set


How to Give Subcutaneous Fluids with a Syringe


Subcutaneous Fluids - Winning Your Vet's Support


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Home > Fluid Therapy > Subcutaneous Fluids

 


Overview


  • Subcutaneous fluids are fluids given under the skin. This means they can be given at home.

  • In the USA and Canada, it is common to give sub-Qs to CKD cats to prevent dehydration. Unfortunately, sub-Qs are not routinely offered in most other countries.

  • This page explains the basics of sub-Qs, including when to start them, how much to give and how often.


What are Subcutaneous Fluids (Sub-Qs)?                                                                   Back to Page Index


 

Subcutaneous means under the skin; so subcutaneous fluids, commonly known as sub-Qs in the USA and subcuts in the UK, are a way of hydrating the cat by carefully introducing fluids under the skin. Instead of placing a slow drip of fluids into the cat's vein, as happens with intravenous (IV) fluids, the fluid is injected just under the skin with a needle. Giving sub-Qs only takes about five minutes and can be easily done by a trained layperson. The fluid then gradually disperses throughout the cat's body, and helps him or her to maintain hydration at the correct level. 

 

The fluids used are particular types of fluid with the correct balance of electrolytes (salts). There are various types of fluids available (see Tips on Giving Subcutaneous Fluids) and your vet can select the fluid most suitable for your cat. 

 


Why Use Subcutaneous Fluids?                                                                                         Back to Page Index


 

The cat is an unusual animal in that it has the ability to concentrate its urine, a little like a camel; this is believed to be a legacy of its African heritage. However, in cats with CKD, this ability gradually disappears, and cats then produce a very dilute urine: the urine looks weaker in colour, has little odour, and the cat will often produce copious amounts. 

 

This increase in urination leads the cat to drink more and more in order to try to avoid becoming dehydrated; and for a time the cat can manage to maintain some kind of balance. Eventually, however, the cat simply cannot drink enough to keep up with its urination rate, and dehydration (which doesn't only mean a loss of body fluids, but also of electrolytes necessary for proper function) occurs. Sometimes this becomes so severe that the cat crashes (i.e. becomes dehydrated enough to need IV treatment at the vet's), as happened to Thomas. 

 

Even if your cat does not suffer such a crisis, the ongoing low-level dehydration that accompanies CKD can be debilitating and uncomfortable; can cause toxin levels in the blood to rise; reduces blood flow through the kidneys, and the kidneys deteriorate even more. Human CKD patients have described dehydration and the accompanying high levels of toxins in the blood as feeling similar to a bad hangover. Therefore the purpose of sub-Qs is to keep your cat nicely hydrated, which in turn should help maintain kidney function and improve his or her well-being by removing that hungover feeling.

 


When To Use Subcutaneous Fluids                                                                                  Back to Page Index


 

Although sub-Qs can be of great benefit to cats who need them, not all CKD cats need them immediately. As mentioned above, the purpose of sub-Qs is to keep the cat hydrated enough to avoid dehydration occurring. However, cats with early stage CKD can usually drink enough to offset their increased urination, and thus do not become dehydrated even without sub-Qs.

 

Processing sub-Qs in itself places an additional workload on the kidneys, plus it can flush out certain nutrients, reduce potassium levels and raise sodium levels. In Staged management of chronic kidney disease in dogs and cats (2009), a Presentation to the 34th World Small Animal Veterinary Association World Congress, Dr David Polzin states "Because recent evidence suggests excessive sodium intake may harm the kidneys, recommendations for long-term sodium administration in any form should be carefully considered."

 

Giving too many fluids or too soon may also increase the risk of overhydration. This is a particular risk for cats with heart problems. Therefore it is best not to begin fluids until the advantages are likely to outweigh the disadvantages i.e. when a cat would become dehydrated without them.

 

Dr Katherine James of the Veterinary Information Network believes that this tends to happen and that most CKD cats will benefit from subcutaneous therapy once creatinine levels are consistently over 3.5-4.0 US (300-350 international). This equates to high Stage 3 of the IRIS staging system. If your vet thinks your cat's CKD is less advanced than this, and your cat does not appear dehydrated, then it is probably safer to hold off on sub-Qs for the moment.

 

However, there are exceptions, and a small number of cats with creatinine below 3.5 US (300 international) may need sub-Qs. This tends to apply to cats whose creatinine is below 3.5 US (300 international) but who previously had a higher level, usually at diagnosis. So if, for example, your cat has creatinine of 6.0 US (550 international) at diagnosis, but this gradually falls to 3.5 US (300 international), s/he will still probably benefit from regular sub-Qs. Cats with pancreatitis are prone to dehydration and may need sub-Qs even if their creatinine level is lower than 3.5 US (300 international).

 

Also, any time more water is going out than is coming in, sub-Qs may be needed short-term. Thus, a CKD cat who is a bit below par because of vomiting or diarrhoea causing dehydration, or who stops eating or drinking, may benefit from sub-Qs as a one-off - my vet gave sub-Qs to my non-CKD cat when she had severe vomiting and diarrhoea for this reason.

 


Amount of Subcutaneous Fluids                                                                        Back to Page Index


 

This is something you need to discuss with your vet, to decide what is right for your cat. When you see recommendations regarding the amount of fluid that a cat needs each day, be aware that often this is total fluid amount. Cats obtain much of their daily fluid requirement from their food and water (most canned food is around 80% water). Therefore Dr Katherine James of the Veterinary Information Network believes that generally speaking, cats do not need more than 100ml of sub-Q fluids a day, though there are exceptions, for example if your cat is particularly large or particularly small.

 

In Staged management of chronic kidney disease in dogs and cats (2009), a Presentation to the 34th World Small Animal Veterinary Association World Congress, Dr David Polzin states: "In patients with signs consistent with chronic or recurrent dehydration, long-term subcutaneous fluid therapy may be considered. Typically, a balanced electrolyte solution (e.g., lactated Ringer's solution) is administered subcutaneously every one to three days as needed. The volume administered depends upon patient size with a typical cat receiving about 75 to 100 ml per dose."

 

Based on what I have seen over the years, the average 8-10lb cat would usually be given around 100ml a day. Larger cats might need 125ml or even occasionally 150ml for cats who weigh 15lb or over, whilst smaller cats need smaller amounts, 50-75ml a day. Be cautious with cats with heart problems, who may have problems processing sub-Qs, and who may need smaller amounts, perhaps given more frequently, for example 50ml twice a day rather than 100ml once a day. Colorado State University College of Veterinary Medicine states "no more than 5 to 10 ml/lb should be given at each injection site" so giving 100ml in one place should not be a problem for a 10lb cat. Some people interpret this to mean it is safe to give 5-10ml/lb to a cat, but the link is referring to how much to inject in one place, not how much to give generally.

 

Since cats vary in their individual needs, you should seek your vet's advice on how much to give your cat, and start off gradually, and aim for the lowest level that will comfortably maintain hydration. If you live in a hot humid area without air conditioning, your cat might need more fluid than a cat in a colder climate. If your cat has a bout of vomiting or diarrhoea or is not eating, more fluids might be required in the short term to offset the fluid lost as a result of the crisis.

 

I suspect that some cats who have had severe crashes may possibly require more fluids than cats who are diagnosed early and whose CKD progresses gradually. Thomas wasn't a massive cat, but he still required 300ml a day to start with following his crash. Even after his creatinine level stabilised at 316 (US: 3.5), he still required 200ml a day, divided into two sessions, in order to maintain hydration.

 

The key words in the previous sentence are "in order to maintain hydration". If your cat's bloodwork worsens, this doesn't automatically mean that the fluid amount should be increased. Giving more than is needed to maintain hydration is a strain on the kidneys (see when to use subcutaneous fluids), can make a cat feel uncomfortable, and of course costs more.

 

When deciding on how much fluid to give, you need to monitor your cat for dehydration and check that the fluid is being properly absorbed. A pouch is normal, and it usually takes 6-8 hours for the fluids to be absorbed, though some cats take longer. Many people find the simplest way to monitor their cat's need for fluids is by means of a weighing scale: you can weigh your cat regularly and if his/her weight goes down, this may indicate dehydration; if the cat's weight increases, the cat may be retaining fluid and at risk of overhydration. Coco's Page has more information on how to do this.

 

If you have the level of sub-Qs right, your cat will no longer drink massive amounts of water.

 

If your cat's bloodwork improves, or your cat seems to stop absorbing the fluids, it may be that s/he needs fewer or no fluids. Ask your vet about reducing or stopping the fluids, but this should be done gradually so as to give your cat's damaged kidneys time to adjust. The same applies if your vet has prescribed fluids for a low numbers cat - ask about stopping fluids to see how your cat manages, but do it slowly.

 


If Your Vet Recommends Large Amounts of Fluid                                     Back to Page Index


 

Fluids are not a benign treatment and more is not always better - giving too much fluid can be dangerous. Unfortunately I have noticed that some vets recommend giving rather large amounts of fluid. In most cases this is not necessary, and in fact carries risks: it increases the sodium load on the kidneys, which may contribute to the development of hypertension, and in the worst case it may cause overhydration. Some vets claim that it is impossible to overhydrate a cat with sub-Qs, but if you give a 10 lb cat 300ml of fluids a day, that is the equivalent of giving a 150lb person 4.5 litres of water a day, far in excess of the amount most people (or cats) can process. I have heard from a number of people who have learnt the hard way about the risks of overhydration, and some of their cats sadly died as a result. In Renal disease (2006), Dr D Polzin states "Chronic subcutaneous fluid therapy can result in fluid overload in some patients, particularly when fluid volumes in excess of those recommended here are used. We have seen several cats given large quantities of fluid (200 to 400 ml/day) present with severe dyspnea due to pleural effusion. This condition can usually be avoided by reducing the volume of fluids administered." He mentions that the presence of metabolic acidosis increases the risk of pulmonary oedema in cats receiving fluid therapy..

 

Don't panic over this but do keep an eye on your cat when administering sub-Qs and watch for the warning signs of overhydration. See above for tips on gradually reducing the amount of fluid you give.

 

Colorado State University briefly discusses fluid therapy and assessing dehyration.

Coco's Page has information on calculating how much fluid is necessary, though please do not alter the amounts you give without your vet's knowledge and approval.

 


Frequency of Sub-Qs                                                                                           Back to Page Index


 

This depends to a large extent upon your cat's individual needs. The majority of cats receive sub-Qs every day. However, some cats on Tanya's CKD Support Group only need fluids 2-3 times a week; whilst a small percentage, like Thomas, become dehydrated very quickly without twice daily fluids (these cats are often cats who have suffered a severe crash at diagnosis). Discuss your cat's particular requirements with your vet, and aim for a consistent, regular approach.

 

It is usually better to give smaller amounts more often, e.g. to give 100ml every day rather than 200ml every other day. If you think about it, this makes sense - if your goal is to drink eight glasses of water each day, it is better if you drink eight each day rather than sixteen on one day and nothing at all on the next day - the same principle applies to sub-Qs.

 

I don't really understand why vets sometimes recommend sub-Qs once a week. It seems too infrequent to make any real difference. However, it can certainly be worth giving sub-Qs as a one-off to a cat who develops dehydration from vomiting or diarrhoea, or if you experience a heatwave and don't have air conditioning.

 

Every now and then, you may have to skip a sub-Q sesssion, perhaps because you are sick or your cat refuses to co-operate. Missing one session is not cause for concern with most cats, but aim for consistency overall.

 


Will My Cat Always Need Subcutaneous Fluids?                                           Back to Page Index


 

If you start fluids at the right time, i.e. only when they are necessary to prevent your cat from becoming dehydrated (which for most cats occurs once creatinine levels are consistently over 300 -350 (US: 3.5-4), then yes, your cat will probably always need them. However, there are always exceptions. Some cats may only need fluids to help them after a crisis (such as when they have severe diarrhoea or vomiting which makes them dehydrated), for example, particularly if they are young or if their bloodwork is normally reasonably good.

If you do ever try to decrease or stop sub-Qs, it is very important to do this slowly, because CKD kidneys cannot adjust to changes as easily as healthy kidneys.


How to Give Subcutaneous Fluids                                                                     Back to Page Index


 

There are two main ways of giving sub-Qs, either via a giving set or via syringe. Most people in the USA use the giving set method; people offered sub-Qs in the UK (very uncommon) are usually offered the syringe method. For those who struggle with needles, another possibility is to use an implanted catheter.

Giving Set Method


The giving set method is similar in some ways to an IV drip, except that you are placing the fluid under the skin rather than into a vein. You are also giving a smaller amount of fluid more quickly. You will need fluids, needles and venosets (IV sets). You use the venoset to connect the bag of fluid to the needle which is then inserted under the skin. The fluid bag is hung high, so gravity makes the fluid drip through the venoset and the needle and into the cat.

There are links to videos showing how to use this method, and photos modelled by Thomas's friend, Purr Box, on the How to Give Subcutaneous Fluids with a Giving Set page.

There are more tips on how to prepare and give sub-Qs here.

Syringe Method


With this method, you also inject the fluid under the skin, but instead of using a venoset (a tube which carries the fluid from the fluid bag to the needle), you remove the fluid from the fluid bag with a syringe, then attach the needle to the syringe and place it under the skin. You then gently squeeze the syringe so the fluid goes into the cat. This method means it is easier to know how much fluid you are giving and is also usually quicker. If you use this method, you will need fluids, needles and syringes.

There are links to videos showing how to use this method, and photos modelled by Thomas, on the How to Give Subcutaneous Fluids with a Syringe page.

There are more tips on how to prepare and give sub-Qs here.


How to Cope with Giving Subcutaneous Fluids                                                    Back to Page Index


If, like me, you have a needle phobia, you will be feeling sick at the mere idea. Yet I stuck a needle into Thomas twice a day for almost eight months, and it honestly does get easier. I used to dread it in the early days, far more than Thomas did; yet soon it became just part of everyday life, like brushing teeth. We were used to it, he was used to it - it took just ten minutes a day to give him his fluids and his medications.

 

Remember, you are doing this to help your cat. Cornell University College of Veterinary Medicine has a video on how to give sub-Qs which states "This might be THE most important thing that you can do at home to help your cat." If fluids are necessary, they can make an amazing difference to how your cat feels - it is like watering a plant in a drought and watching it bloom again. Once you see the difference that fluids make, you should be able to find the strength from somewhere. During the last twelve years I have heard of literally thousands of people who have regularly given their cats fluids; and I can only recall one person who was unable to overcome her needle phobia (she did not even try to give sub-Qs). So read Sandi's story below, check out the tips on how to give them here, take a deep breath and give it a go. If you'd like to have your hand held while you get used to it, join Tanya's CKD Support Group

Coco's page gives tips and also advice on the emotional side of giving sub-Qs.

Elisa and Samantha's page describes Elisa's routine for giving fluids to Samantha.

Some people are put off the idea of giving sub-Qs because their vet charges them a ridiculous amount for their supplies - the most expensive I heard of was US52 for one bag of fluid! Quite outrageous when you know that people in the US and Canada people can buy supplies very cheaply, paying only US$16-40 for an entire case of twelve bags! The Obtaining Supplies Cheaply page gives tips on where to find fluids and other sub-Q supplies at good prices in the USA, UK and Canada.

 

Sandi and Maz - Learning to Cope with Fluids


Here Sandi describes how she overcame her needle phobia and successfully gave Maz his fluids before she lost him in October 2007.

 

"I know that some of you are really nervous/uneasy about having to do SubQ's yourself, so I thought my story may help.

 

First, I have to say I am the world's biggest needlephobic person (don't ask what's it's like when I need blood taken!). So when Maz was diagnosed last October and I found out he had to be on Sub-Qs I cried for a day, out of fear of doing SubQ's and also because I thought I was losing Maz. Luckily a vet tech saw my tears and agreed to come to my house three times a week (I paid her $45 including supplies).

 

This went on for about six months. During that time though I would be the one to get Maz when she came over (he would always try and hide) and gently pet him while he was getting the fluids. I began to get used to seeing the needle go in and also through this group started learning a tremendous amount on making it more comfortable (warming etc). The tech started telling me I knew as much as she did about giving fluids and Maz would probably be more comfortable if I did it but I resisted, saying I just couldn't stick my baby boy. Well, in April she got a new job and there wasn't another vet tech who could come. So now, it would really be ALL UP TO ME! I was petrified but with the help of the tech, I just did what I had to do. I learned that heating the fluids made all the difference and that by giving Maz some treats, other than the first needle poke, he forgets all about the fluids and just likes getting treats (some Fancy Feast) and a lot of love. There are times he even purrs now!

 

I have to admit, I still don't like poking him (I take a minute or two to get myself psyched for it), then I gently let him know I'm going to give him his treatment, take him into the bathroom where his favorite towel and treats are waiting and go for it!

 

So please believe me when I say it's not as bad as it seems, read the posts on the group and the info on Helen's website and you will see in no time, you and your furbabies will be just fine!

 

Hope this helps!"

 


The Giftube, Endo-Sof Catheter or Skin Button                                             Back to Page Index


If you really cannot bear giving sub-Qs, or if your cat really fights them, you may want to consider whether to use an implantable tube. These products are implanted in the cat under anaesthetic, and thereafter the fluids are basically just poured in (though you should not give too much, of course).

The most commonly used tube in the USA is the Giftube. This stands for Greta Implantable Fluid Tube and is named after the patient, Greta, for whom the inventor created it. Having one fitted costs around US$200-300. There is a similar product called the Endo-Sof subcutaneous catheter (also known as the Cooks Catheter), which tends to be offered in the UK.

It can be hard to get your vet to agree to you doing sub-Qs at home in the UK, but if your vet does agree, it is sometimes on the basis of using one of these products. This is not ideal because the infection rate for these products is over 10%, which I find worrying. It is also extremely expensive, because a bag of fluid can only be used for one sub-Q session before it is thrown away (because of the risk of infection); plus many cats have to have two or more tubes implanted each year because of problems with the previous tube necessitating its removal. This is usually because the cat's body considers the tube to be a foreign body and may form a kind of membrane around it, which can prevent the fluids entering the cat's body smoothly. In addition, many cats find the tube irritating and scratch at it constantly, so they often have to wear a bandage or little sweater to hold the tube in place.

Therefore I would strongly recommend using standard methods and only using these products as a last resort. If you do decide to use one, please ensure your vet knows what s/he is doing: some people have discovered after the tube has been implanted that their vet has never implanted one before and their cat has basically been a guinea pig; I'd prefer to know that beforehand and be sure that my vet could help me deal with any problems that might arise.

There is another more recently introduced product called a Skin Button which uses a mechanism called hypodermoclysis. The Skin Button is a small circle similar in size to a coat button, and like a coat button, it has two parts, one on the top and one on the underside. Unlike the other two products, this can be placed with local anaesthetic rather than general anaesthetic. The skin is supposed to grow around the button and reduce the risk of bacteria entering. Unfortunately it carries similar risks of irritation to the Giftube and Endo-Sof catheter, and can clog easily. It costs roughly US$100 plus your vet's fee. It also requires the use of a special needle which increases the cost.

 

Subcutaneous fluid port-associated soft tissue sarcoma in a cat (2013) McLeland SM, Imhoff DJ, Thomas M, Powers BE & Quimby JM Journal of Feline Medicine and Surgery 15(10) pp917-920 reports on a case of cancer in a cat who had a fluid port for four years. The report concludes "Although the catís owners were pleased with the 4 years of quality of life provided by this device, this complication should be considered when a decision to place ports for long-term management of disease is made." As an aside, the cat in question was twenty years old and had had CKD for ten years, quite an achievement.

 

Mar Vista Vet has information on all three products, including photos of the skin button.

Hypodermoclysis: an alternative infusion technique (2001) Sasson M & Shvartzman P American Family Physician 64(9) pp1575-8 discusses the use of skin buttons in humans.

PractiVet - the Giftube manufacturer's website.

Dechra Veterinary Products has information on placement and usage of the Endo-Sof catheter.

Mila International is the site of the manufacturer of the Skin Button.

Norfolk Vet Products also make a type of Skin Button. This site is currently being remodelled and does not contain too much information.

Giftube Users Forum - for people using the tube or contemplating its use. This site is owned by Practivet and therefore puts a very positive spin on the use of the tube.

   


When NOT to Give Subcutaneous Fluids                                                                      Back to Page Index


Fluids are not always acceptable treatment, and should only ever be administered with veterinary approval. Subcutaneous fluids should NOT be administered to your cat if any of the following criteria apply:

  1. Your cat is so severely dehydrated that your vet considers intravenous fluid therapy (IV) more appropriate. In certain circumstances IV is the only correct treatment, because sub-Qs are not well absorbed in a severely dehydrated cat.

  2. If your cat has high bloodwork levels (creatinine over 7), s/he might benefit more from IV fluids initially, with sub-Qs provided once s/he returns home as needed.

  3. 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.

  4. Your vet has refused to agree to the procedure on other medical grounds.

  5. fluids from the previous session have not yet been absorbed.

  6. 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

  7. Processing the extra fluids in itself places an additional workload on the kidneys which can make the CKD progress faster; plus it can flush out certain nutrients, and giving fluids when they are not needed may increase blood pressure; so it is best not to begin fluids until the advantages are likely to outweigh the disadvantages. Dr Katherine James of the Veterinary Information Network believes that most CKD cats will benefit from subcutaneous therapy once creatinine levels are consistently over 300 -350 (US: 3.5-4). If your vet thinks your cat's CKD is less advanced than this, then it is probably safer to hold off on sub-Qs for the moment;

  8. 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.  

  9. 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.

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This page last updated: 24 June 2014

 

Links on this page last checked: 10 April 2012

 
   

Website last updated: 26 June 2014

 

See above for when this particular page was last updated

 

*****

 

TREATING YOUR CAT WITHOUT VETERINARY ADVICE CAN BE EXTREMELY DANGEROUS.

 

I have tried very hard to ensure that the information provided in this website is accurate, but I am NOT a vet, just an ordinary person who has lived through CKD with three cats. This website is for educational purposes only, and is not intended to be used to diagnose or treat any cat. Before trying any of the treatments described herein, you MUST consult a qualified veterinarian and obtain professional advice on the correct regimen for your cat and his or her particular requirements; and you should only use any treatments described here with the full knowledge and approval of your vet. No responsibility can be accepted.

 

If your cat appears to be in pain or distress, do not waste time on the internet, contact your vet immediately.

 

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