TANYA'S

COMPREHENSIVE GUIDE TO

FELINE CHRONIC KIDNEY DISEASE

 

 

 

WAYS TO MAKE GIVING SUBCUTANEOUS FLUIDS EASIER

 

ON THIS PAGE:


Choosing a Fluid


Preparation


Fluid Preparation


Needles


Fluid Administration Sets


Preparing Your Cat (Includes the Clothes Pin Trick)


The Big Moment!


Afterwards


Re-use and Disposal of Needles and Adminstration Sets


 

 

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What You Need to Know First


Alphabetical Index


Glossary


Research Participation Opportunities


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WHAT IS CKD?


What Happens in CKD


Causes of CKD


How Bad is It?


Is There Any Hope?


Acute Kidney Injury


 

KEY ISSUES


Nausea, Vomiting, Appetite Loss and Excess Stomach Acid


Maintaining Hydration


The Importance of Phosphorus Control


All About Hypertension


All About Anaemia


All About Constipation


Potassium Imbalances


Metabolic Acidosis


Kidney Stones


 

SUPPORT


Coping with CKD


Tanya's Support Group


Success Stories


 

SYMPTOMS


Alphabetical List of Symptoms and Treatments


Fluid and Urinary  Imbalances (Dehydration, Overhydration and Urinary Issues)


Waste Product Regulation Imbalances (Vomiting, Appetite Loss, Excess Stomach Acid, Gastro-intestinal Problems, Mouth Ulcers Etc.)


Phosphorus and Calcium Imbalances


Miscellaneous Symptoms (Pain, Hiding Etc.)


 

DIAGNOSIS: WHAT DO ALL THE TEST RESULTS MEAN?


Blood Chemistry: Kidney Function, Potassium, Other Tests (ALT, Amylase, (Cholesterol, Etc.)


Calcium, Phosphorus, Parathyroid Hormone (PTH) and Secondary Hyperparathyroidism


Complete Blood Count (CBC): Red and White Blood Cells: Anaemia and Infection


Urinalysis (Urine Tests)


Other Tests: Ultrasound, Biopsy, X-rays etc.


Renomegaly (Enlarged Kidneys)


Which Tests to Have and Frequency of Testing


Factors that Affect Test Results


Normal Ranges


International and US Measuring Systems


 

TREATMENTS


Which Treatments are Essential


Fluid and Urinary Issues (Fluid Retention, Infections, Incontinence, Proteinuria)


Waste Product Regulation (Mouth Ulcers, GI Bleeding, Antioxidants, Adsorbents, Azodyl, Astro's CRF Oil)


Phosphorus, Calcium and Secondary Hyperparathyroidism (Calcitriol)


Miscellaneous Treatments: Stem Cell Transplants, ACE Inhibitors - Fortekor, Steroids, Kidney Transplants)


Antibiotics and Painkillers


Holistic Treatments (Including Slippery Elm Bark)


ESAs (Aranesp, Epogen etc.) for Severe Anaemia


General Health Issues in a CKD Cat: Fleas, Arthritis, Dementia, Vaccinations


Tips on Medicating Your Cat


Obtaining Supplies Cheaply in the UK, USA and Canada


Working with Your Vet and Recordkeeping


 

DIET & NUTRITION


Nutritional Requirements of CKD Cats


The B Vitamins (Including Methylcobalamin)


What to Feed (and What to Avoid)


Persuading Your Cat to Eat


Food Data Tables


USA Canned Food Data


USA Dry Food Data


USA Cat Food Manufacturers


UK Canned Food Data


UK Dry Food Data


UK Cat Food Manufacturers


2007 Food Recall USA


 

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


Dialysis


 

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Home > Fluid Therapy > Subcutaneous Fluids Tips

 


Overview


  • The very idea of giving subcutaneous fluids to your cat be pretty scary at first, but there are ways to make it easier for both you and your cat.

  • The type of fluid you use can make a lot of difference to your cat's comfort levels. This page explains more about the different types of fluids that are available.

  • It also discusses the best type of needles (Terumo), how to prepare and calm your cat (including the famous clothes pin trick) and what to expect both during and after the procedure.


Key Tips                                                                                                                  Back to Page Index


Giving sub-Qs for the first time is scary! It may never be something you look forward to, but there are ways to make the process go more smoothly which not all vets are aware of, so they may not tell you about them. If you follow these tips, you and your cat still may not necessarily enjoy the process (although some cats realise that sub-Qs make them feel better and actually remind their human if they are late giving them!), but it should make it tolerable for you both.

 

Remember, you're doing this to help your cat. Sub-Qs do help!

 

The key tips:

  1. Warm the fluids. Cold fluids can be very uncomfortable.

  2. Use Terumo UTW (ultra thin walled needles). These can make an incredible difference to your cat's comfort level yet few vets use them. 

  3. You don't have to only use the scruff of the neck. You can use the area that would be covered by a saddle.

  4. Try to get into a routine. Most cats like routine. Even if your cat never grows to like sub-Qs, if s/he knows you always do them at 6 p.m., s/he will remain relaxed around you the rest of the time (yes, of course cats can tell the time!).

  5. Is your cat the demon cat from hell? Try the clothes peg (clothes pin) trick! It can often make even the wildest cat co-operate.

 


Choosing a Fluid                                                                                                                       Back to Page Index


 

There are several different types of fluid. Isotonic fluids are fluids which have the same sodium concentration as body tissues. Hypotonic fluids have a lower salt concentration, whereas hypertonic fluids have a higher salt concentration. When giving sub-Q fluids, you usually use isotonic fluids.

 

There are a variety of fluid types available, but the fluid that is most commonly used for CKD cats is Lactated Ringers Solution (LRS). Occasionally other fluid types are prescribed, usually because of other issues which need addressing. If your vet gives you another type of fluid, do check this is necessary because some other types can sting. Please also always check the bag of fluid before you start to use it in case you have been given the wrong type: mistakes can happen.

 

International WIN shows the contents of commonly used fluids.

Introduction to fluid therapy (2008) Dr S DiBartola has information about different fluid types and explains why LRS is the best choice for sub-Qs for cats.

 

Lactated Ringers Solution (LRS)


Human patients with kidney disease are given solutions containing a buffer such as lactate known as Lactated Ringers Solution (LRS), and this is also the most common choice for cats given sub-Qs. The nearest British equivalent (it is virtually identical) is called Aqupharm No. 11 Hartmann's solution, although you may also be offered Vetivex 11.

 

The lactate in LRS is important for CKD cats because lactate is metabolised by the liver where it is converted to bicarbonate, and this aids in the correction of mild acidosis;  However, LRS may not be the best choice for cats with cancers such as lymphoma, which can cause lactate to accumulate.

 

Introduction to fluid therapy (2008) Dr S DiBartola discusses why LRS is the best choice for most cats on sub-Qs.

 

Normosol-R/PlasmaLyte A/Isolyte-S


This is a type of fluid which is sometimes used instead of Lactated Ringers when a cat has high calcium levels, liver problems or lymphoma (a form of cancer). Normosol-R is the most commonly prescribed, but you may also be offered PlasmaLyte A, or occasionally Isolyte-S. They are all basically the same type of fluid, but different manufacturers use different trade names.

If you are using Normosol, you need Normosol-R, not Normosol-M: the latter contains dextrose (see below).

 

There are two versions of Normosol-R, one with a pH of 6.6 (similar to LRS, which has a pH of 6.5) and one with a pH of 7.4. PlasmaLyte A aso has a pH of 7.4. For cats with high calcium levels, the more alkaline varieties (pH of 7.4) may be a better choice. 

 

These products contain magnesium, so may not be suitable if your cat has high magnesium levels; they also seem to sting some cats or make them twitch when the fluids are administered (see Symptoms for other possible causes of more frequent twitching), so cats may resist being given this type of fluid. A lot of vets don't seem to be aware of this possibility but Managing fluid and electrolyte disorders in renal failure (2008) Langston CE Veterinary Clinics Small Animal Practice 38 pp677-697 states (page 11) "Plasmalyte is reported to sting when administered SC." Introduction to fluid therapy (2008) Dr S DiBartola states "The low pH and high acetate content of some Plasmalyte products and Normosol R may contribute to pain on subcutaneous injection."

 

There have also been quite a few reports of cats vomiting after being given this type of fluid. All of these products are also more expensive than Lactated Ringers and may be harder to find. I therefore recommend that, if at all possible, you should use lactated ringers instead.

 

Saline Solution (Sodium Chloride or NaCl)


Saline solution is sometimes suitable for cats with high calcium levels, but it is usually too acidic for a CKD cat, plus it can sting when injected subcutaneously which may make the cat resist fluids; it also lacks the buffer contained in lactated ringers, and does not have added potassium, which many CKD cats need. It is also not usually suitable for cats with hypertension or liver problems. However, it may be helpful for cats with hyperkalaemia (high levels of potassium).

 

One fluid manufacturer, Hospira, recalled some of its sodium chloride fluids in June 2012, so check you do not have any of the affected batches.

 

Dextrose


These fluids contain dextrose, a form of sugar. The number of calories contained in the fluid is of little benefit to cats (8.5 calories per 100ml of fluid), but the sugar means that bacteria can easily grow in the fluid and cause infection at the injection site. Fluids containing dextrose may also sting when administered via sub-Qs. Fluids containing dextrose also have a shorter life than non-dextrose fluids. If your vet gives you this fluid (it may be a bag of LRS to which 2.5% or 5% dextrose has been added, so always check bags carefully before using them), ask to exchange it for a more suitable type.

 

Pet Place discusses the need to avoid giving sub-Qs with added dextrose.

Introduction to Fluid Therapy Dr S DiBartola discusses why fluids containing dextrose are best avoided for sub-Qs for cats.

Managing fluid and electrolyte disorders in renal failure (2008) Langston CE Veterinary Clinics Small Animal Practice 38 pp677-697 states (page 11) "Dextrose-containing fluids increase the risk of abscess formation... when administered SC."

 

DEHP-Free Bags


The plastic of some fluid bags contain a chemical called DEHP, which softens the bags. Some people prefer not to use bags containing DEHP because they are concerned that some of the DEHP may leach into the fluids themselves, especially if the bag is warmed before use.

 

Health Canada mentions that studies into the effect of DEHP on mice and rats found that they developed liver tumours, but this was after they were fed DEHP in high doses. I am not aware of any studies into the effect of DEHP on cats. The US Food & Drug Administration has concluded that "there is little or no risk posed by patient exposure to the amount of DEHP released from PVC IV bags during the infusion of crystalloid fluids (e.g., normal saline, D5W, Ringer's Lactate)".

 

I would probably avoid DEHP bags myself if I could find an alternative. I understand that the B Braun, Baxter and Hospira brands in the USA offer DEHP-free bags which cost around $0.50 a bag more. As at June 2014 it was virtually impossible to obtain DEHP-free fluids in the USA because of supply problems, and I know some people are very concerned about this. Personally, if I couldn't find or afford DEHP-free bags, it is not something I would lose sleep over - in my opinion, it is more important that a cat who needs fluids receives them.

 


Preparation                                                                                                                                    Back to Page Index


Preparation is the key with sub-Qs. You want to have the best equipment possible, and you want to have a system in place to increase your chances of success. But it is fine to buy a few supplies from your vet to tide you over until you've read through this page and the Obtaining Supplies Cheaply page and sorted out your supplies.

 

The first thing to do is to practise giving sub-Qs - on an orange. The feel of a needle going into an orange is similar to that of a needle going into a cat, so give it a go and see how it feels. Just use the needle, don't bother with the fluids. You just want to feel the sensation. You can also practise on a piece of raw chicken with skin. Try to inject the needle between the skin and the muscle.

 

If you give your first sub-Q to your cat at the vet's, you may well find your cat behaves better there, so don't be surprised if your cat is less co-operative at home, where s/he does not expect this sort of treatment and is probably less fearful and therefore less afraid of letting you know what s/he thinks! You may also find that your first few sessions at home go well, but then your cat starts to object. This is also normal.

 

Most people do find that their cat eventually accepts sub-Qs at home. If you don't succeed, don't beat yourself up but instead look into alternatives, such as having a vet nurse/tech come to your home to help you, or taking your cat to the vet for treatment.


Fluid Preparation                                                                                                  Back to Page Index


Fluid Storage and Lifespan


A bag of fluids should ideally 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 probably 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.

 

Some people do use bags for longer than ten days without problems. In fact, Assessment of sterility of fluid bags maintained for chronic use (2011) Matthews KA & Taylor DK Journal of the American Association for Laboratory Animal Science 50(5) pp708–712 did find that "fluid bags used chronically can be maintained in a sterile condition for a maximum of 30 days" but that study was using syringes to remove the fluid from the bags (see How to Give Subcutaneous Fluids: Syringe Method) rather than using giving sets. Personally, I would err on the side of caution because CKD cats are immune-compromised, but if you do decide (with your vet's approval) to keep an opened fluid bag for longer than ten days, I would not keep it beyond thirty days.

 

Fluids may be kept in the fridge and removed shortly before use, but if you are going to use up the bag  within ten days of opening it, it is usually not necessary to refrigerate it - they are not usually refrigerated in hospitals. The US National Library of Medicine mentions that fluids should be stored at room temperature of 25° C (about 65° F). We stopped refrigerating our fluids and had no problems.

 

Regardless of how long each bag lasts, always check the bag before each use. 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 with condensation, particularly if you have just removed it from the fridge, but if the contents themselves look cloudy, that is a red flag.

 

Fluid Warming


When used straight from the fridge or even at room temperature, many cats find the fluids uncomfortable and may twitch, so you should warm the fluids 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) is not immersed, and leave to warm for ten minutes. Some people have found that filling a cooler box with hot water works well. Alternatively, you could use a heatpad to warm the fluids.

Make sure the fluids are not so hot that they will burn your cat! You can buy an infrared digital thermometer to check the temperature - I bought one from Radio Shack which cost about US$10.

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 in places.

A small number of cats do prefer the fluids at room temperature so experiment to see what works best for you both.

If you take your cat to the vet for fluids, you may find they do not warm them. Discuss with them whether it would be possible to do so if you think it would make your cat more comfortable.


All About Needles                                                                                                                      Back to Page Index


Needles should not be used more than once (see below to understand why). If you don't get the needle in correctly the first time, throw it away and use a new one.

 

A needle is and should be sterile, so only remove the protective covering or cap when you are about to use it.

 

Choosing Needles: Terumos


Many vets routinely stock Monoject needles. Some people use these without any problem, and many people use them initially when they have not yet had time to shop around for supplies. However, the best needles for CKD cats are widely considered to be the needles intended for humans made by Terumo. These needles are extremely fine but still very 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, as shown here (this link changes frequently, if it doesn't work, visit the Terumo link above and click on "Download Neolus needles pdf file" at the bottom of the page to see exactly how they work).

 

If you haven't yet used Terumo needles, give them a try. I regularly hear from people who cannot believe the difference they make! Ordinary needles are sometimes referred to as "kitty harpoons" on the support group, but Terumos slide in like a knife through butter.

 

Unfortunately Terumo is discontinuing the ultra thin wall needles. They have a veterinary range called Sur-Vet. At the moment (June 2014) only thin wall needles seem to be available in this range rather than ultra thin wall needles, though Terumo claims that the Sur-Vet range is 18% sharper than those produced by the leading veterinary needle manufacturer. An October 2013 press release stated that the Sur-Vet range will grow to include needles recently discontinued in the human market, which hopefully means that ultra thin wall needles will be made available again in due course. In the meantime, Nipro make an ultra thin walled needle called Flomax, but I don't know anyone who has tried this type yet.

 

You can obtain details of mail order suppliers for needles in Obtaining Supplies Cheaply - you can expect to pay around US$6-10 for 100 needles.

 

Some people find it can be hard to take 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.

 

Choosing Needles: Size and Speed


The size of needle used can make a tremendous difference to your and your cat's comfort and stress levels. Most people use needles between a size 18 and a size 23, and those using a size 20 or above usually opt for the UTW Terumos intended for humans rather than the veterinary type because they have the ultra thin wall. 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). Above size 23 can mean it takes too long to give the fluids. The length of the needle is a personal choice, most people seem to like the 1 inch length.

 

On the packet it will say something like 21G x 5/8". The first number with the G is the gauge, i.e. the needle size. The second number is the length of the needle in inches, so this needle is 5/8 inches long.

 

If your cat dislikes fluids, you need to decide if it is the actual sticking that bothers him/her, or if it's the length of time it takes. If it is the sticking that is an issue, opt for the human type size 20 or above UTW Terumos.  If it's the length of time it takes to give the fluids, opt for a size 18 or 19 which will get the job done quicker. Most Tanya's CKD Support Group members use size 19 or 20 because these give a balance between size of needle and speed of fluid flow.

 

Rad, whose lovely cat, Purr Box, is the model in How to Give Subcutaneous Fluids: Giving Set Method, ran an experiment regarding the flow rate of various needles. Here are the results of his experiment, which he has kindly given me permission to publish here. The flow rates (all for 100ml of fluid) are in minutes and seconds.

 

Brand and Size

Length (inches)

Type

First Flow Test

Second Flow Test

Average Flow Rate

Terumo 18

1 TW

00:55

00:51

00:53

Monoject 19

1 n/a

01:11

01:09

01:10

Becton Dickinson 18

1 n/a

01:14

01:10

01:12

Terumo 19

1 TW

01:17

01:16

01:16

Monoject 18

1 n/a

01:15

01:18

01:17

Terumo 20

1 UTW

02:02

01:56

01:59

Becton Dickinson 20

1 n/a

02:28

02:29

02:29

Monoject 20

1 n/a

02:32

02:34

02:33

Terumo 21 1 UTW

02:39

02:37

02:38

Terumo 22

1 UTW

04:05

04:13

04:09

Terumo 21 (Sur-Vet Label)

1 TW

05:59

05:53

05:56

Monoject 22

0.75 n/a

06:04

06:12

06:08

Monoject 22

1 n/a

06:21

06:08

06:15

Terumo 23

1 UTW

07:16

07:03

07:09

Monoject 22

1.5 n/a

07:21

07:13

07:17

Terumo 25

1 UTW

13:21

13:20

13:20

TW Thin Wall

UTW Ultra Thin Wall

 

Freezing Needles


Some people freeze needles before using them. This is because of a study, Pain associated with injection using frozen versus room-temperature needles (2001) Denkler K 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.

 

It may not be your cat you're worried about when it comes to needles, but yourself! I did master the art of giving sub-Qs despite my needle phobia. In over ten years of running this site, I've only heard of one person who did not master sub-Qs because of a needle phobia. She never even tried to give them (in her case, her needle phobia was insurmountable). Please give it a try. It's much cheaper for you and less stressful for your cat if you learn to give sub-Qs yourself at home.

 

After you've given your cat fluids, remove the needle from the end of the line and place a new needle complete with cover on, ready for your next session.

 


IV Administration Sets (Venosets or Giving Sets)                                      Back to Page Index


If you are giving sub-Qs by letting the fluid drip out of the bag (giving set method), you need a venoset, also known as an IV administration set. You usually need a prescription (it depends which state you live in).

 

Ideally you want a 10 drop/ml or 15 drop/ml venoset - higher numbers will take longer to give. Venosets are usually 80 or 100 inches long, and most people seem to like the 80 inch ones.

 

As with fluid bags, you may wish to use a DEHP-free set. Hospira is one such brand.

 

Some venosets have a luer lock to lock the needle in place, which most people find helpful. Some venosets have a port which you can use to add certain medications. If you do this, make sure you only use medications in a form suitable for this purpose.

 

Most people use the administration set for 2-3 bags of fluid, as long as the end to which the needle is attached is kept sterile. When you want to remove the needle from the administration set, it can be rather difficult. Using pliers or a pair of rubber gloves can help.

 

See the Obtaining Supplies Cheaply page for stockists.

 

Mar Vista Vet has a helpful video about preparing for giving fluids.

Dr Mike Ontiveros has a video which shows how to prepare a venoset for sub-Q fluids.

 

IV Pole


Since giving fluids via a giving set relies on gravity to deliver the fluids, many people try to hang the fluid bag high up so as to speed up the process. You can use a coathanger, but some people decide to buy an IV pole. This can be wheeled to your cat, which can be helpful if your cat copes better with fluids while sleepy.

 

Amazon sells a suitable pole for less than $30 with free shipping.

Dr C Wladis explains how the height of the fluid bag affects the speed of delivery.

 


Preparing Your Cat                                                                                              Back to Page Index


 

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 cats tolerate sub-Qs better if they are sleepy.

 

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.

 

Here are some methods which people have found makes the process easier.

 

Calming Methods - Feliway or Zylkene


 

Feliway


Feliway is a copy of the pheromones naturally present on a cat's face. When a cat rubs his face on something, s/he is marking it with these pheromones, which make the cat feel more relaxed. Some people find Feliway can be helpful when giving sub-Qs. You can buy Feliway plug-ins and simply leave them on in the room where you usually give fluids, or you can use the spray version.

 

Petguys sells plug-in Feliway for US$23.99 in USA, with refills costing US$13.99.

Entirely Pets also sells Feliway, for similar prices.

Vet UK sells Feliway in the UK.

 

Zylkčne


Zylkčne is a natural product derived from casein, the protein in milk. Effect of alpha-casozepine (Zylkene) on anxiety in cats (2007) Beata C, Beaumont-Graff E, Coll V, Cordel J, Marion M, Massal N, Marlois N & Tauzin J Journal of Veterinary Behavior: Clinical Applications and Research 2(2), pp40–46 found that it seems to be effective, and it does seem to help some cats to accept sub-Qs.

 

Zylkčne is often available from vets in Europe. In the USA you can find it on Amazon. You can open the capsule and mix its contents with food.

 

Distraction and Bribery


Some cats can be distracted with a little food during sub-Qs. Cookie on the left was the sort of cat who needed to be sedated for blood draws, yet as you can see he had no problems receiving sub-Qs, and could easily be distracted during the procedure with food, so no restraint was necessary. I think this is a great photo for showing sceptical vets that many cats can tolerate sub-Qs very well.

 

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. 

 

Restraint


Some cats do better if they are restrained during sub-Qs, either by hand or by a cat restraint bag, or in a carrying basket with a top opening. However, others are more likely to co-operate if they are not restrained and feel they have some kind of control. If your cat tends not to like being held generally, s/he probably won't like to be held during the sub-Q process either. You know your cat best so decide which would be better. 

 

There is also something called the Thundershirt. This is not a restraint device but rather a coat that provides gentle, constant pressure which is supposed to reduce anxiety. Cummings School of Veterinary Medicine at Tufts University is running a trial into the efficacy of this product. It is intended for dogs, and I don't know anybody who has used it for a cat but I wonder if it might help. Please do not use without your vet's approval.

 

Learning the most important pet handling skills in thirty minutes is an article by Dr Sophie Yin which explains how to recognise fear in cats.

Handling a difficult cat is a video by Dr Yin on how to handle a difficult cat simply using a couple of blankets.

Washington State University College of Veterinary Medicine has information on how to restrain a cat.

Four Flags in the 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. I put this on my cat and was surprised to see that she didn't mind it at all.

Amazon also sells the Cat Sack in various sizes at various prices.

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

Pet Edge sells grooming bags, which can be used as restraint bags, for US$6.99-10.99.

DVM News Magazine shows you how to make a restraint bag from an old pair of jeans.

EZ IV Harness has been used by some members of Tanya's CKD Support Group. This can be shipped internationally.

 

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 back in 2000 to a lady called Lori. Here, Joan's Sassy models this trick. Sassy, left, was not a particularly placid cat, but this method enabled 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.

 

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

 

Eight years after I first mentioned this technique, a study was published, 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."

 

You can buy special clips for this purpose now from the Clipnosis Store but they work in exactly the same way as clothes pegs, and clothes pegs are much cheaper and easier to obtain quickly.

 

In 2011 I was concerned to learn that several members of the Association for Pet Behaviour Counsellors have reservations about the use of this technique. They believe that whilst the cat may appear calm and submissive, s/he is actually very stressed. In this sense it would be very similar to the way rabbits trance when you flip them on their backs which is extremely stressful for rabbits. I am investigating this further. Ohio State University College of Veterinary Medicine reports on the rationale for the above study and their interpretation of the behaviour of the cats in the trial, whom they consider were not stressed.

 

Thanks to Lori for providing this helpful tip back in February 2000 and giving me permission to share it here, and thanks to Joan and Sassy for the photos.

 


The Big Moment!                                                                                                    Back to Page Index


So you've got your bag of fluid, your nice sharp needle, your venoset or syringe and your cat, so you're all ready to go. And you're terrified. Don't worry, that is completely normal. The first time might go well or it might not. Don't worry if it's a bit of a disaster, if you don't get all (or even any) of the fluid in - many people only get 30ml or so in the first time. You are going to get better at this!

 

Having said that, do try to think positive. Your cat will sense if you are fearful, and may react to this, creating a vicious circle. So think positive, and remember, you will both adapt, especially once you and your cat realise how much better s/he feels afterwards.

 

Remember, cats can be good at giving you a guilt trip. Some cats make a fuss even if the needle is not in! But if it does turn into a bad session, let it go and try again later or the next day.

The website most people find most helpful when they are getting started is Sophia gets her subcutaneous fluids. You can also visit these pages with photos of giving sub-Qs to see the two different ways of giving sub-Qs:

The Saddle Area


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.

 

Numbing or Cleaning the Area


Some people use lidocaine but it is not recommended because it can be toxic to cats. Pet Place states "Caution should be used whenever lidocaine is given to cats since they tend to be especially sensitive to the drug." In Antiarrhythmic therapy (2009) Dr LK Maxwell says "Cats have been used as a model species for lidocaine toxicity and have historically been considered to be particularly sensitive to the CNS [central nervous system] and arrhythmogenic side effects of lidocaine." In any event, if you use sharp needles, sub-Qs are really not that painful.

 

You also don't need to wipe with alcohol first. It needs time to work, about 30 minutes, and since most people don't wait that long, it's a bit pointless. Washington State University College of Veterinary Medicine explains why wiping with alcohol isn't necessary unless the cat has a poor immune system. Although CKD cats are immune-compromised, most seem to have no problems even if their skin is not cleaned. If you are concerned, ask your vet about using chlorhexidine (hibiscrub). You only need to wait 30 seconds for it to take effect but it should not be removed until you've finished giving the sub-Qs.

 

The Tent


You will find it easier to inject your cat if you form a good tent (pouch) with the skin. On the left you can see us making a tent on Thomas.

 

One reader asked me to mention that if your cat wears a collar and you give fluids nearby, you need to make sure the collar does not become uncomfortably tight as a result.

 

 

Inserting the Needle


Before you insert the needle, check to see it is smooth and sharp - very occasionally, the needles are faulty and have a little barb which makes inserting it uncomfortable. If your cat normally doesn't flinch when you insert the needle, but suddenly does so, this might be the cause.

 

Another reason why your cat might flinch when you insert the needle is that you hit a muscle. Just withdraw the needle, reassure your cat, and try again in another spot (with a new needle) .

 

Flinching 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. Incidentally, some cats flinch even when you are only pretending to insert a needle!

 

You need to insert the needle the right way up. The needle will look like this from the side: ______\ or this:  l____. Holding the needle parallel to your cat's back, insert the needle smoothly into the tent you have formed. Clocktower Animal Hospital has a diagram showing how to insert the needle.

 

 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.

 

If the needle slips out, try again with another needle. However, I would not stick a cat more than twice in one session, so if the needle slips out more than once, I would give up and try again another time.

 

Trouble Inserting the Needle - Thick Skin


Sometimes the skin may feel tough so it is hard to get the needle in. There are a number of possible reasons for this. Firstly, perhaps surprisingly, it can indicate dehydration, in which case your cat definitely needs the fluids. Secondly, it may indicate scar tissue. This is actually not that common, and usually doesn't happen for a long time (months to years) but one way to avoid it is to rotate where you give fluids (see above).

 

Stabbing Yourself with the Needle


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, or if you are worried, seek medical advice - if you're not up to date on your tetanus shots, you may be advised to have one.


Giving the Fluids                                                                                                   Back to Page Index


The actual process should only take 2-5 minutes. If it's taking longer than this, you need to work out why. Some people with fidgety cats find using a pressure infusor helps the fluids flow more quickly, though you have to be careful not to make them flow so quickly that it is uncomfortable for the cat. The Society of Critical Care Medicine explains more about how these work.

 

If your cat is calm intially but then fights you after a minute or two, it might be because you are giving too much fluid in one spot and it is becoming uncomfortable - generally speaking, you should not give more than 100ml in one spot. Also make sure you are holding the needle in place, so it does not move and irritate your cat.

 

Measuring the Fluid


If you are using the Syringe Method, you can measure the amount you give very accurately.

 

I've also heard of one or two people using a buretrol set (burette) to help them measure the fluid - this is a device which allows you to transfer a measured amount of fluid from the fluid bag into a chamber, then you give the fluid from the chamber. The ABCs of IVs has a clearer picture of a buretrol.

 

Progressive Medical sells buretrols.

Emergency Medical Products sells buretrols for US$6.59 each.

 

In the USA, there are markings on the bag, but you don't always get this in the UK. Do not mark the bag with a permanent marker (sharpie) because the ink can leach through to the fluids. Hanging scales can help you work out how much fluid you have given if you are using a giving set. Pesola is a popular brand. One member of  Tanya's CKD Support Group uses scales she found on Amazon UK. 100ml is 100gram.

 

We have given 120ml in one spot 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 Sub-Qs                                                                                                           Back to Page Index


Most cats feel better after receiving fluids, and are often more active, with a better appetite. If your cat becomes lethargic after receiving fluids, or loses appetite, this may be a sign of overhydration or heart problems. If your cat vomits, it may be because of the type of fluid you are using (see above). Speak to your vet about this.

 

Leaking Fluid


You may also see a bit of fluid leaking out on to your cat's fur after you remove the needle: again, this is normal. If you pinch or massage the injection area for a minute or so, this will minimise the possibility of fluids leaking.

 

 

 

 

Seeing Blood


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.

 

The Fluid Pouch


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 - think of it like a camel's hump, to keep your cat hydrated. It should be absorbed gradually over 6-8 hours. However, 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 (try to move back slightly); and you should never give more fluid until the fluid in the pouch has been absorbed.

 

Crackling Noise Under the Skin (Subcutaneous Crepitus)


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 subcutaneous crepitus), and should go away on its own in a couple of days. It 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 overhydrated, 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.

 


Re-Using Supplies                                                                                                                         Back to Page Index


 

Re-using Venosets


Most people change the venoset every time they change the fluid bag, though some people use them for two fluid bags. If you do this, switch the line to the new bag as soon as you've finished the first bag, making sure not to contaminate it.

 

Re-using Needles


This is not recommended, because using a needle just once blunts and distorts the needle which means using it again makes it more painful for the cat. The Melanotan Website and Children with Diabetes both show photographs of how a used needle looks - scary! Re-using a needle also increases the risk of infection, not a good idea with an immune-compromised cat.

 

You can obtain needles very cheaply (around US$6 for 100 online, see Obtaining Supplies Cheaply) so it's really best to use each needle only once.

 

Needle Disposal


Most countries have laws about putting used needles in the trash. If you are in the USA, you can check your state's laws at the Environmental Protection Agency website. You can usually buy a sharps disposal unit from your vet or local pharmacy for a few dollars or pounds, or some vets may allow you to return used needles to them for free.

 

 

 

Back to Page Index

 

This page last updated: 25 June 2014

 

Links on this page last checked: 11 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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