Fluid Preparation
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Fluid Storage and Lifespan
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 - 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.
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 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
longer than ten days without problems, but it is a potential risk because
CKD cats are immune-compromised.
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. 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
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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 then 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 (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. 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. You can obtain details of mail order suppliers in
Obtaining
Supplies Cheaply - you can expect to pay around US$6-7 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 CRF 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 are in minures
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, 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.
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.
All About IV Administration Sets (Venosets or
Giving Sets)
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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
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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.
Feliway
Some people find
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.
Entirely Pets also sells Feliway, for
similar prices.
Vet UK sells Feliway in the UK.
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 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 how she didn't mind it at all.
Amazon also sell the Cat Sack in
various sizes at various prices.
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.
Pet Edge sells grooming bags, which can
be used as restraint bags, for US$8.99-10.99.
DVM News Magazine
shows you how to make a restraint bag from an old pair of jeans.
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. Below, 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.
The Big Moment!
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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, e.g. also has cancer. If you use chlorhexidine (hibiscrub),
which is also unnecessary in most cases, 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.
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
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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.
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.
Life Assist sells these at US$90 for
five.
In the USA, there are markings on the bag, but you don't always get this
in the UK.
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
ofSUPPORT GROUP uses scales she found on
Amazon UK.
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
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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
over-hydration
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.
ccc
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. 
