2013 AAHA/AAFP Fluid Therapy Guidelines for Dogs and Cats*

Harold Davis, BA, RVT, VTS (ECC), Tracey Jensen, DVM, DABVP, Anthony Johnson, DVM, DACVECC, Pamela Knowles, CVT, VTS (ECC),
Robert Meyer, DVM, DACVAA, Renee Rucinsky, DVM, DAVBP (Feline), Heidi Shafford, DVM, PhD, DACVAA

Abstract
Fluid therapy is important for many medical conditions in veterinary patients. The assessment of patient history, chief complaint,
physical exam findings, and indicated additional testing will determine the need for fluid therapy. Fluid selection is dictated by the
patients needs, including volume, rate, fluid composition required, and location the fluid is needed (e.g., interstitial versus intravascular).
Therapy must be individualized, tailored to each patient, and constantly re-evaluated and reformulated according to changes in status.
Needs may vary according to the existence of either acute or chronic conditions, patient pathology (e.g., acid-base, oncotic, electrolyte
abnormalities), and comorbid conditions. All patients should be assessed for three types of fluid disturbances: changes in volume,
changes in content, and/or changes in distribution. The goals of these guidelines are to assist the clinician in prioritizing goals, selecting
appropriate fluids and rates of administration, and assessing patient response to therapy. These guidelines provide recommendations
for fluid administration for anesthetized patients and patients with fluid disturbances.

Introduction A variety of conditions can be effectively managed using three

These guidelines will provide practical recommendations for fluid types of fluids: a balanced isotonic electrolyte (e.g., a crystalloid
choice, rate, and route of administration. They are organized by such as lactated Ringers solution [LRS]); a hypotonic solution (e.g.,
general considerations, followed by specific guidelines for perianes- a crystalloid such as 5% dextrose in water [D5W]); and a synthetic
thetic fluid therapy and for treatment of patients with alterations colloid (e.g., a hydroxyethyl starch such as hetastarch or tetrastarch).
in body fluid volume, changes in body fluid content, and abnor-
mal distribution of fluid within the body. Please note that these General Principles and Patient Assessment
guidelines are neither standards of care nor American Animal The assessment of patient history, chief complaint, and physi-
Hospital Association (AAHA) accreditation standards and should cal exam findings will determine the need for additional testing
not be considered minimum guidelines. Instead these guidelines and fluid therapy. Assess for the following three types of fluid
are recommendations from an AAHA/American Association of disturbances:
Feline Practitioners (AAFP) panel of experts. 1. Changes in volume (e.g., dehydration, blood loss)
Therapy must be individualized and tailored to each patient 2. Changes in content (e.g., hyperkalemia)
and constantly re-evaluated and reformulated according to 3. Changes in distribution (e.g., pleural effusion)
changes in status. Fluid selection is dictated by the patients needs, The initial assessment includes evaluation of hydration, tissue
including volume, rate, and fluid composition required, as well perfusion, and fluid volume/loss. Items of particular importance
as location the fluid is needed (interstitial versus intravascular). in evaluating the need for fluids are described in Table 1. Next,
Factors to consider include the following: develop a treatment plan by first determining the appropriate
yy Acute versus chronic conditions route of fluid administration. Guidelines for route of administra-
yy Patient pathology (e.g., acid-base balance, oncotic pressure, tion are shown in Table 2.
electrolyte abnormalities) Consider the temperature of the fluids. Body temperature
yy Comorbid conditions (warmed) fluids are useful for large volume resuscitation but

From the University of California Davis, Veterinary Medical Teaching Hospital, Davis, CA (H.D.); *This document is intended as a guideline only. Evidence-based support for specific recommendations
Wellington Veterinary Clinic, PC, Wellington, CO (T.J.); Department of Veterinary Clinical Sciences, has been cited whenever possible and appropriate. Other recommendations are based on practical
College of Veterinary Medicine, Purdue University, West Lafayette, IN (A.J.); WestVet Animal clinical experience and a consensus of expert opinion. Further research is needed to document
Emergency and Specialty Center, Garden City, ID (P.K.); Mississippi State University College of some of these recommendations. Because each case is different, veterinarians must base their
Veterinary Medicine, Mississippi State, MS (R.M.); Mid Atlantic Cat Hospital, Cordova, MD (R.R.); and decisions and actions on the best available scientific evidence, in conjunction with their own
Veterinary Anesthesia Specialists, LLC, Milwaukie, OR (H.S.). expertise, knowledge, and experience. These guidelines are supported by a generous educational
grant from Abbott Animal Health.
Correspondence: shafford@vetanesthesiaspecialists.com (H.S.) and arpest7@hotmail.com (R.R)

AAFP, American Association of Feline Practitioners; AAHA, American Animal Hospital Association; BP, blood pressure; D5W, 5% dextrose in water; DKA, diabetic ketoacidosis; K, potassium; KCl, potassium
chloride; LRS, lactated Ringers solution
5
2013 AAHA/AAFP Fluid Therapy Guidelines for Dogs and Cats

provide limited usefulness at low IV infusion rates. It is not pos- Alternatively, fluid made up of equal volumes of replacement solu-
sible to provide sufficient heat via IV fluids at limited infusion tion and D5W supplemented with K (i.e., potassium chloride
rates to either meet or exceed heat losses elsewhere.1 [KCl], 1320 mmol/L, which is equivalent to 1320 mEq/L)
would be ideal for replacing normal ongoing losses because of the
Fluids for Maintenance and Replacement lower Na and higher K concentration. Another option for a main-
Whether administered either during anesthesia or to a sick patient, tenance fluid solution is to use 0.45% sodium chloride with 1320
fluid therapy often begins with the maintenance rate, which is the mmol/L KCl added.5 Additional resources regarding fluid therapy
amount of fluid estimated to maintain normal patient fluid bal- and types of fluids are available on the AAHA and AAFP websites.
ance (Table 3). Urine production constitutes the majority of fluid
loss in healthy patients.2,3 Maintenance fluid therapy is indicated Fluids and Anesthesia
for patients that are not eating or drinking, but do not have vol- One of the most common uses of fluid therapy is for patient
ume depletion, hypotension, or ongoing losses. support during the perianesthetic period. Decisions regarding
Replacement fluids (e.g., LRS) are intended to replace lost body whether to provide fluids during anesthesia and the type and
fluids and electrolytes. Isotonic polyionic replacement crystalloids volume used depend on many factors, including the patients
such as LRS may be used as either replacement or as maintenance signalment, physical condition, and the length and type of the
fluids. Using replacement solutions for short-term maintenance procedure. Advantages of providing perianesthetic fluid therapy
fluid therapy typically does not alter electrolyte balance; however, for healthy animals include the following:
electrolyte imbalances can occur in patients with renal disease or yy Correction of normal ongoing fluid losses, support of
in those receiving long-term administration of replacement solu- cardiovascular function, and ability to maintain whole
tions for maintenance. body fluid volume during long anesthetic periods
Administering replacement solutions such as LRS for mainte- yy Countering of potential negative physiologic effects associated
nance predisposes the patient to hypernatremia and hypokalemia with the anesthetic agents (e.g., hypotension, vasodilation)
because these solutions contain more sodium (Na) and less potas- yy Continuous flow of fluids through an IV catheter prevents
sium (K) than the patient normally loses.Well-hydrated patients clot formation in the catheter and allows the veterinary
with normal renal function are typically able to excrete excess team to quickly identify problems with the catheter prior
Na and thus do not develop hypernatremia. Hypokalemia may to needing it in an emergency
develop in patients that receive replacement solutions for mainte- When fluids are provided, continual monitoring of the
nance fluid therapy if they are either anorexic or have vomiting or assessment parameters is essential (Table 1). The primary risk of
diarrhea because the kidneys do not conserve K very well.4 providing excessive IV fluids in healthy patients is the potential for
If using a replacement crystalloid solution for maintenance vascular overload. Current recommendations are to deliver 10
therapy, monitor serum electrolytes periodically (e.g., q 24 hr). mL/kg/hr to avoid adverse effects associated with hypervolemia,
Maintenance crystalloid solutions are commercially available. particularly in cats (due to their smaller blood volume), and all
patients anticipated to be under general anesthesia for long periods
of time (Table 4).68 In the absence of evidence-based anesthesia
TABLE 1 fluid rates for animals, the authors suggest initially starting at 3
mL/kg/hr in cats and 5 mL/kg/hr in dogs. Preoperative volume
Evaluation and Monitoring Parameters that May loading of normovolemic patients is not recommended.
Be Used for Patients Receiving Fluid Therapy The paradigm of crystalloid fluids at 10 mL/kg/hr, with
higher volumes for anesthesia-induced hypotension is not evi-
yy Pulse rate and quality yy Packed cell volume/total solids
dence-based and should be reassessed. Those high fluid rates may
yy Capillary refill time yy Total protein
actually lead to worsened outcomes, including increased body
yy Mucous membrane color yy Serum lactate
weight and lung water; decreased pulmonary function; coagula-
yy Respiratory rate and effort yy Urine specific gravity
tion deficits; reduced gut motility; reduced tissue oxygenation;
yy Lung sounds yy Blood urea nitrogen
increased infection rate; increased body weight; and positive fluid
yy Skin turgor yy Creatinine
balance, with decreases in packed cell volume, total protein con-
yy Body weight yy Electrolytes
centration, and body temperature.9,10 Note that infusion of 1030
yy Urine output yy BP
mL/kg/hr LRS to isoflurane-anesthetized dogs did not change
yy Mental status yy Venous or arterial blood gases
either urine production or O2 delivery to tissues.11 A fluidconsum-
yy Extremity temperature yy O2 saturation
ing third space has never been reliably shown, and, in humans,
BP, blood pressure. blood volume was unchanged after overnight fasting.12

6
 2013 AAHA/AAFP Fluid Therapy Guidelines for Dogs and Cats

2013 AAHA
Preanesthetic Fluids and Preparing the Sick Patient yy Provide an IV bolus of an isotonic crystalloid such as LRS
Correct fluid and electrolyte abnormalities in the sick patient as (310 mL/kg). Repeat once if needed.
much as possible before anesthesia by balancing the need for pre- yy If response is inadequate, consider IV administration of a
anesthetic fluid correction with the condition requiring surgery. colloid such as hetastarch. Slowly administer 510 mL/kg
For example, patients with uremia benefit from preanesthetic for dogs and 15 mL/kg for cats, titrating to effect to
fluid administration.13 Further, develop a plan for how fluids will minimize the risk of vascular overload (measure BP every
be used in an anesthesia-related emergency based on individual 35 min).9 Colloids are more likely to increase BP than
comoribund conditions, such as hypertrophic cardiomyopathy crystalloids.15
and oliguric/polyuric renal disease. yy If response to crystalloid and/or colloid boluses is
inadequate and patient is not hypovolemic, techniques
Monitoring and Responding to Hypotension During Anesthesia other than fluid therapy may be needed (e.g., vasopressors
Blood pressure (BP) is the parameter often used to estimate tis- or, balanced anesthetic techniques).9
sue perfusion, although its accuracy as an indicator of blood flow yy Caution: Do not use hypotonic solutions to correct
is not certain.11,14,15 Hypotension under anesthesia is a frequent hypovolemia or as a fluid bolus because this can lead to
occurrence, even in healthy anesthetized veterinary patients. hyponatremia and water intoxication.
Assess excessive anesthetic depth first because it is a common
cause of hypotension.7,16 Exercise caution when using fluid ther- Postanesthetic Fluid Therapy
apy as the sole method to correct anesthesia-related hypotension Postanesthetic fluid administration varies based on intra-anes-
as high rates of fluids can exacerbate complications rather than thetic complications and comorbid conditions. Patients that
prevent them.10,11 may benefit from fluid therapy after anesthesia include geriatric
If relative hypovolemia due to peripheral vasodilation is con- patients and patients with either renal disease or ongoing fluid
tributing to hypotension in the anesthetized patient, proceed as losses from gastrointestinal disease. Details regarding anesthesia
described in the following list: management may be found in the AAHA Anesthesia Guidelines for
yy Decrease anesthetic depth and/or inhalant concentration. Dogs and Cats.17

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2013 AAHA/AAFP Fluid Therapy Guidelines for Dogs and Cats

Fluid Therapy in the Sick Patient high risk of fluid overload include those with heart disease, renal
First, determine the initial rate and volume based on whether the disease, and patients receiving fluids via gravity flow.16
patient needs whole body rehydration or vascular space volume Cats require very close monitoring. Their smaller blood vol-
expansion. Next, determine the fluid type based on replacement and ume, lower metabolic rate, and higher incidence of occult cardiac
maintenance needs as described in the following sections. Fluid ther- disease make them less tolerant of high fluid rates.7,18
apy for disease falls into one or more of the following three categories:
the need to treat changes in volume, content, and/or distribution. Changes in Fluid Volume
Typically, the goal is to restore normal fluid and electrolyte sta-
tus as soon as possible (within 24 hr) considering the limitations
of comoribund conditions. Once those issues are addressed, the Examples of Common Disorders
rate, composition, and volume of fluid therapy can be based on Causing Changes in Fluid Volume
ongoing losses and maintenance needs. Replace the deficit as well Dehydration from any cause
as normal and abnormal ongoing losses simultaneously (e.g., con- Heart disease
tinued vomiting/diarrhea as described below in the Changes in Blood loss
Fluid Volume section). Accurate dosing is essential, particularly
in small patients, to prevent volume overload.
The physical exam will help determine if the patient has whole
Monitor Response to Fluid Therapy body fluid loss (e.g., dehydration in patients with renal disease),
Individual patients fluid therapy needs change often. Monitor for vascular space fluid loss (e.g., hypovolemia due to blood loss),
a resolution of the signs that indicated the patient was in need of or hypervolemia (e.g., heart disease, iatrogenic fluid overload).
fluids (Table 1). Monitor for under-administration (e.g., persistent Acute renal failure patients, if oliguric/anuric, may be hypervol-
increased heart rate, poor pulse quality, hypotension, urine output), emic, and if the patient ispolyuric they may become hypovolemic.
and overadministration (e.g., increased respiratory rate and effort, Reassessment of response to fluid therapy will help refine the
peripheral and/or pulmonary edema, weight gain, pulmonary determination of which fluid compartment (intravascular or
crackles [a late indicator]) as described in Table 1. Patients with a extravascular) has the deficit or excess.

TABLE 2
Determining the Route of Fluid Administration

Patient parameter Route of fluid administration

Gastrointestinal tract is functional and no contraindications exist Per os

(e.g., vomiting)

Anticipated dehydration or mild fluid volume disturbances in an Subcutaneous. Caution: use isotonic crystalloids only. Do not use
outpatient setting dextrose, hypotonic (i.e., D5W), or hypertonic solutions.
Subcutaneous fluids are best used to prevent losses and are not
adequate for replacement therapy in anything other than very
mild dehydration

Hospitalized patients not eating or drinking normally, anesthetized IV or intraosseous

patients, patients who need rapid and/or large volume fluid
administration (e.g., to treat dehydration, shock, hyperthermia,
or hypotension)

Critical care setting. Used in patients with a need for rapid and/ Central IV
or large volume fluid administration, administration of hypertonic
fluids and/or monitoring of central venous pressure

D5W, 5% dextrose in water.

8
 2013 AAHA/AAFP Fluid Therapy Guidelines for Dogs and Cats

Dehydration
Estimating the percent dehydration gives the clinician a guide
in initial fluid volume needs; however, it must be considered an
estimation only and can be grossly inaccurate due to comorbid
conditions such as age and nutritional status (Table 5).

Fluid deficit calculation

Body weight (kg) % dehydration = volume (L) to correct
General principles for fluid therapy to correct dehydration
include the following:
yy Add the deficit and ongoing losses to maintenance
volumes. Replace ongoing losses within 23 hr of the loss,
but replace deficit volumes over a longer time period. The
typical goal is to restore euhydration within 24 hr (pending
limitations of comorbid conditions such as heart disease).
yy Frequency of monitoring will depend on the rate at which
fluid resuscitation is being administered (usually q 1560
min). Assess for euhydration, and avoid fluid overload
through monitoring for improvement. 2013 AAHA
yy Maintenance solutions low in Na should not be used
to replace extracellular deficits (to correct dehydration)
because that may lead to hyponatremia and hyperkalemia TABLE 3
when those solutions are administered in large volumes. Recommended Maintenance Fluid Rates49

Hypovolemia Cats Dogs

Hypovolemia refers to a decreased volume of fluid in the vascular
Formula: Formula:
system with or without whole body fluid depletion. Dehydration is
80 body weight (kg)0.75 per 24 hr 132 body weight (kg)0.75 per 24 hr
the depletion of whole body fluid. Hypovolemia and dehydration
Rule of thumb: Rule of thumb:
are not mutually exclusive nor are they always linked. Hypotension
23 mL/kg/hr 26 mL/kg/hr
may exist separately or along with hypovolemia and dehydration
(Figure 1). Hypotension is discussed under Fluids and Anesthesia.
Common causes of hypovolemia include severe dehydration,
rapid fluid loss (gastrointestinal losses, blood, polyuria), and TABLE 4
vasodilation. Hypovolemic patients have signs of decreased tis- Recommendations for Anesthetic Fluid Rates
sue perfusion, such as abnormal mentation, mucous membrane
color, capillary refill time, pulse quality, pulse rate, and/or cold yy Provide the maintenance rate plus any necessary replacement
extremity temperature. rate at 10 mL/kg/hr
Hypovolemia due to decreased oncotic pressure is suspected in yy Adjust amount and type of fluids based on patient
patients that have a total protein 35 g/L (3.5 g/dL) or albumin assessment and monitoring
15 g/L (1.5 g/dL).19 Patients in shock may have hypovolemia, yy The rate is lower in cats than in dogs, and lower in patients
decreased BP, and increased lactate ( 2 mmol/L).2022 Note that with cardiovascular and renal disease
cats in hypovolemic shock may not be tachycardic.
yy Reduce fluid administration rate if anesthetic procedure lasts
Treating hypovolemia 1 hr
When intravascular volume expansion without whole blood is yy A typical guideline would be to reduce the anesthetic
needed, use crystalloids, colloids, or both. IV isotonic crystalloid fluid rate by 25% q hr until maintenance rates are reached,
fluids are the initial fluid of choice. If electrolytes such as K are provided the patient remains stable
needed in the emergent situation, administer through a second IV Rule of thumb for cats for initial rate: 3 mL/kg/hr
catheter. High K administration rates may lead to cardiac arrest; Rule of thumb for dogs for initial rate: 5 mL/kg/hr
therefore, do not exceed 0.5 mmol/kg/hr.2325

9
2013 AAHA/AAFP Fluid Therapy Guidelines for Dogs and Cats

How to administer crystalloids the effects of hypertonic saline administration. The typical
yy Standard crystalloid shock doses are essentially one hydroxyethyl starch dose for the dog is up to 20 mL/kg/24
complete blood volume.26 hr (divide into 5 mL/kg boluses and reassess). For the cat,
yy Shock rates are 8090 mL/kg IV in dogs and 5055 mL/ the dose range is 1020 mL/kg/24 hr (typically, 10 mL/kg
kg IV in cats. in 2.53 mL/kg boluses).2931 Titrate the amount of colloid
yy Begin by rapidly administering 25% of the calculated infused to effect.
shock dose. Reassess the patient for the need to continue at
each 25% dose increment. Simultaneously administering crystalloids and colloids
yy Monitor signs as described in the patient assessment yy Use this technique when it is necessary to both increase
portion of this document. In general, if 50% of the intravascular volume (via colloids) and replenish interstitial
calculated shock volume of isotonic crystalloid has not deficits (via crystalloids).
caused sufficient improvement, consider either switching yy Administer colloids at 510 mL/kg in the dog and 15
to or adding a colloid. mL/kg in the cat. Administer the crystalloids at 4045
yy Once shock is stabilized, replace initial calculated volume mL/kg in the dog and 2527 mL/kg in the cat, which is
deficits over 68 hr depending on comorbidities such as equivalent to approximately half the shock dose. Titrate
renal function and cardiac disease. to effect and continually reassess clinical parameters to
adjust rate and type of fluid administered (crystalloid and/
or colloid).

hypovolemic
Using hypertonic saline
yy To achieve the greatest cardiovascular benefit with the
least volume of infused fluids (typically reserved for large
patients or very large volume losses).
yy To achieve translocation of fluids from the interstium to
hypotensive dehydrated
the intravascular space (e.g., for initial management of
hemorrhage).
Figure 1 yy In animals with hemorrhagic hypovolemic shock as a
fast-acting, low-volume resuscitation. Shock doses of
Patients may be hypovolemic, dehydrated, hypotensive,
or a combination of all three.

TABLE 5
When to administer colloids
Dehydration Assessment
yy When it is difficult to administer sufficient volumes of
fluids rapidly enough to resuscitate a patient and/or when Dehydration Physical exam findings*
achieving the greatest cardiovascular benefit with the least
volume of infused fluids is desirable (e.g., large patient, Euhydrated Euhydrated (normal)
emergency surgery, large fluid loss). Mild ( 5%) Minimal loss of skin turgor, semidry
yy In patients with large volume losses where crystalloids are mucous membranes, normal eye
not effectively improving or maintaining blood volume
restoration. Moderate ( 8%) Moderate loss of skin turgor, dry
yy When increased tissue perfusion and O2 delivery is mucous membranes, weak rapid pulses,
needed.27 enophthalmos
yy If edema develops prior to adequate blood volume
Severe ( 10%) Considerable loss of skin turgor, severe
restoration.
enophthalmos, tachycardia, extremely
yy When decreased oncotic pressure is suspected or when the
dry mucous membranes, weak/thready
total protein is 35 g/L (or albumin is 15 g/L).
pulses, hypotension, altered level of
yy When there is a need for longer duration of effect.
consciousness50
Preparations vary, and some colloids are longer lasting than
crystalloids (up to 24 hr).28 Use of colloids can prolong * Not all animals will exhibit all signs.

10
 2013 AAHA/AAFP Fluid Therapy Guidelines for Dogs and Cats

hypertonic saline are 45 mL/kg for the dog and 24 Patients with body fluid content changes include those with
mL/kg for the cat. Direct effects of hypertonic saline last electrolyte disturbances, blood glucose alterations, anemia, and
3060 min in the vascular space before osmotic forces polycythemia. Patient assessment will dictate patient fluid content
equilibrate between the intra and extravascular space. Once needs. It is acceptable, and often desirable, to initiate fluid therapy
the patient is stabilized, continue with crystalloid therapy with an isotonic balanced crystalloid solution while awaiting the
to replenish the interstitial fluid loss. electrolyte status of the patient. Tailor definitive fluid therapy as
yy In conjunction with synthetic colloids to potentiate the the results of diagnostic tests become available.
effects of the hypertonic saline.28,29
yy Do not use hypertonic saline in cases of either Hyperkalemia
hypernatremia or severe dehydration. Suspect hyperkalemia in cases of obvious urinary obstruction,
uroabdomen, acute kidney injury, diabetic ketoacidosis (DKA), or
Treating hypovolemia due to blood loss changes on an electrocardiogram. If life-threatening hyperkalemia
The decision of when to use blood products instead of balanced is either suspected or present (K 6 mmol/L), begin fluid therapy
electrolyte solutions is based on the severity of estimated blood immediately along with medical therapy for hyperkalemia.35
loss. Use of blood products is addressed elsewhere.32,33 If blood There are several benefits associated with administering
products are not deemed necessary, note that patients with low K-containing balanced electrolyte solutions pending labora-
vascular volume (due to either vasodilation or hemorrhage) will tory test results. Volume expansion associated with the fluid
benefit more from the use of colloids than crystalloids. Following administration results in hemodilution and lowering of serum
15 mL/kg of hemorrhage, even 75 mL/kg of crystalloid will not K concentration. The relief of any urinary obstruction results in
return blood volume to prehemorrhage levels because crystalloids kaliuresis that offsets the effect of the administered K. The relative
are highly redistributed. Large volumes may be needed to achieve alkalinizing effect of the balanced solution promotes the exchange
blood volume restoration goals, and large volumes may be det- of K with hydrogen ions as the pH increases toward normal.
rimental to patients with normal whole body fluid volume but Most K-containing balanced electrolyte solutions contain
decreased vascular volume resulting from acute blood loss.34 lower K concentrations than those typically seen in cats with ure-
thral obstruction, so the use of such solutions does not affect blood
Hypervolemia K in those cats.36 LRS contains 4 mmol/L, which is typically much
Hypervolemia can be due to heart failure, renal failure, and/or lower than the serum K levels in cats with urethral obstruction.
iatrogenic fluid overload. Hypertension is not an indicator of
hypervolemia. Treatment is directed at correcting underlying Hypokalemia
disease (e.g., chronic renal disease, heart disease), decreasing or Charts are available in many texts to aid in K supplementation of flu-
stopping fluid administration, and (possibly) use of diuretics. ids and determination of administration rate.37 It is essential to mix
Consider using hypotonic 0.45% sodium chloride as maintenance added KCl thoroughly in the IV bag as inadvertent K overdoses can
fluid therapy in patients susceptible to volume overload (such as occur and are often fatal. Do not exceed an IV administration rate
those with heart disease) due to the decreased Na load. of 0.5 mmol/kg/hr of K.38 If hypophosphatemia exists along with
hypokalemia (e.g., DKA), use potassium phosphate instead of KCl.
Hyperthermia
Increased body temperature can rapidly lead to dehydration. Hypernatremia
Treatment includes administering IV replacement fluids while Hypernatremia may be common, yet mild and clinically silent.Causes
monitoring for overhydration. Subcutaneous fluids are not ade- of hypernatremia include loss of free water (e.g., through water depri-
quate to treat hyperthermia. vation), and/or iatrogenically (through the long-term use [ 24 hr]
of replacement crystalloids). Another cause of hypernatremia is salt
Changes in Fluid Content toxicity (through oral ingestion of high salt content materials).
Provide for ongoing losses and (in hypotensive patients) vol-
ume deficits with a replacement fluid having a Na concentration
Examples of Common Disorders Causing
close to that of the patients serum (e.g., 0.9% saline). Once volume
Changes in Fluid Content
needs have been met, replace the free water deficit with a hypotonic
Diabetes solution (e.g., D5W). Additionally, for anorexic patients, provide
Renal disease maintenance fluid needs with an isotonic balanced electrolyte
Urinary obstruction solution. The cause and duration of clinical hypernatremia will
dictate the rate at which Na levels can be reduced without causing

11
2013 AAHA/AAFP Fluid Therapy Guidelines for Dogs and Cats

cerebral edema. Do not exceed changes in Na levels of 1 mmol/hr in refractometry. Therefore, patient assessment determines
acute cases or 0.5 mmol/hr in chronic cases because of the risk of cere- response.43 Use up to 20 mL/kg/day of hetastarch for dogs
bral edema. Although the complexities of managing Na disorders and 1020 mL/kg/day for cats.2931
often benefits from the involvement of a specialist/criticalist, this
is not always feasible. The amount of free water (in the form of Hyperglycemia
D5W) to infuse over the calculated timeframe (to decrease the Na Fluid therapy in hyperglycemic patients is aimed at correcting
concentration by the above guidelines) can be calculated as follows: dehydration and electrolyte abnormalities. Monitor the patient
Volume (L) of free water (D5W) needed = to guide the rate of correction. As with hyperkalemia, the choice
([current Na concentration/normal Na concentration] 1) of initial replacement fluid is not as important as correcting the
(0.6 body weight [kg])33 patients hydration status. See the AAHA Diabetes Management
Guidelines for details on managing hyperglycemia.44
Hyponatremia
Hyponatremia is most commonly seen in DKA and with water Hypoglycemia
intoxication. Changes in serum Na levels must occur slowly, as Initial therapy for hypoglycemia is based on severity of clini-
with hypernatremia. Monitor electrolyte levels frequently, and use cal signs more than on laboratory findings. Treatment options
a fluid with Na content similar to the measured plasma Na to keep include oral glucose solutions, IV dextrose-containing fluids, or
the rate of change at an appropriate level. food (if not contraindicated). To prepare a dilute dextrose solu-
In patients with water intoxication, restrict water and/or use tion of 2.55% dextrose, add concentrated stock dextrose solution
diuretics with caution. Patients with DKA may have pseudohypo- (usually 50% or 500 mg/mL) to an isotonic balanced electrolyte
natremia associated with osmotic shifts of water following glucose solution (e.g., add 100 mL of 50% dextrose to 900 mL of fluid to
into the intravascular space. In pseudohyponatremia, a relation- make a solution containing 5% dextrose).
ship exists between serum glucose and serum Na levels: the higher
the glucose, the lower the Na. Specifically, for every 100 mg/dL Anemia and Polycythemia
increase in serum glucose over 120 mg/dL, the serum Na will Blood products may be needed to treat anemia. The decision to
decrease by 1.6 mmol/L.39 transfuse the anemic patient is not based on either the packed cell
volume or hematocrit alone, but on multiple factors as described
Hypoproteinemia/hypoalbuminemia in the General Principles and Physical Assessment section of this
Colloid osmotic pressure is related to plasma albumin and protein document. Use of blood products is not addressed in this document.
levels and governs whether fluid remains in the vascular space. Blood loss and hemorrhage are discussed above in volume changes.
Fluid loss into the pulmonary, pleural, abdominal, intestinal, or Treatment of symptomatic polycythemia involves reducing the
interstitial spaces is uncommon until serum albumin is 15 g/L number of red blood cells through phlebotomy and replacing the
or total protein is 35 g/L.19,40 Evidence of fluid loss from the vas- volume removed with balanced electrolyte solutions to reduce vis-
cular space is used in conjunction with either serum albumin or cosity and improve blood flow and O2 delivery.
total solid values in determining when to initiate colloid therapy.
Guidelines for fluid therapy when treating hypoalbuminemia Multiple Content Changes
include the following: Many patients present with multiple serum chemistry abnor-
yy Nutritional support is critical to treatment of malities, making appropriate fluid choice problematic. The vast
hypoalbuminemia. majority of patients will benefit from early empirical fluid therapy
yy Plasma administration is often not effective for treatment while awaiting lab results, knowing that more specific treatment
of hypoalbuminemia due to the relatively low albumin will be tailored to individual needs as diagnostic information
levels for the volume infused. Human serum albumin is becomes available.
costly and can cause serious hypersensitivity reactions.41
Canine albumin is not readily available in most private Changes in Fluid Distribution
practice settings but may be the most efficient means of
supplementation when available.42
yy Synthetic colloids (e.g., hydroxyethyl starch) are beneficial Examples of Common Disorders Causing
because they can increase oncotic pressure in patients Changes in Fluid Distribution
with symptomatic hypoalbuminemia to maintain fluid Any disease causing pulmonary or peripheral edema
in the intravascular space; however, synthetic colloids Any disease causing pleural or abdominal effusion
will not appreciably change total solids as measured by

12
 2013 AAHA/AAFP Fluid Therapy Guidelines for Dogs and Cats

Fluid distribution abnormalities include edema (pulmonary, General Guidelines for IV Fluid Administration
peripheral, interstitial) and effusions (pleural, abdominal, through yy Use a new IV line and bag for each patient, regardless of
the skin of burn patients). Two main causes of edema/effusion are route of administration.46
loss of intravascular oncotic pressure and loss of vascular integrity. yy Ensure lines are primed to avoid air embolism.47
Consider concurrent dehydration and whole patient volume defi- yy Fluid pumps and gravity flow systems require frequent
cits when treating patients with abnormal fluid distribution. monitoring. Check patients with gravity flow systems more
Suggested specific approaches to fluid therapy include the frequently because catheter positioning can affect rate.
following: yy If using gravity flow, select appropriate size/volume bag
yy Pulmonary edema/volume overload: stop fluid for patient size, particularly in small patients, to minimize
administration, consider diuretics, address cardiovascular risk of inadvertent overload if the entire bag volume is
disease if present, and provide mechanical ventilation with delivered to the patient.
positive end-expiratory pressure (if indicated). yy Use a buretrol if frequent fluid composition changes are
yy Pleural/abdominal effusions: stop fluid administration, anticipated to reduce changing entire bag.
administer diuretics if indicated, address cause(s) of yy Consider using T-ports to easily medicate a patient
effusion, perform either abdomino- or thoracocentesis if receiving IV fluids and Y-ports in animals receiving more
respiration is compromised. than one compatible infusion.

Equipment and Staffing

Staffing considerations and a description of useful equipment for
delivery of fluid therapy are described below.

Staff
To optimize the success of fluid therapy, it is critical to pro-
vide staff training on assessment of patient fluid status, catheter
placement and maintenance, use of equipment related to fluid
administration, benefits and risks of fluid therapy, and drug/fluid
incompatibility. A variety of veterinary conferences and online
resources from universities and commercial vendors provide such
continuing education.45
IV fluid administration is ideally monitored continually by
trained technical staff. Without adequate monitoring, severe con-
sequences can occur and patient care is compromised; however,
there are many practices that are either unable to provide 24 hr
care or are geographically unable to refer to a 24 hr facility. If it is
not possible to monitor around the clock and unmonitored fluid
administration is deemed necessary, take the following steps to
make the process as safe as possible:
yy Consider giving higher rate of fluids while staff members
are present, and administer subcutaneous fluids overnight.
yy Use fluid pumps whenever possible, and check them
regularly for proper function and calibration.
yy Use a smaller volume of fluid in the bag to reduce chance
of overloading (note that even 250 mL could fatally
volume-overload a small patient. Know the maximum
volume for safe infusion over a given time [based on rates
described in this document], and match the unattended
volume to that value).
2013 AAHA

yy Consider using an Elizabethan collar to prevent patient

removal of the catheter.
yy Luer lock connections prevent inadvertent disconnection.

13
2013 AAHA/AAFP Fluid Therapy Guidelines for Dogs and Cats

yy Consider using a syringe pump to either infuse small

amounts of fluids or to provide a constant rate infusion.
For small volume infusions, place the end of the extension
set associated with the small volume delivered close to the
patients IV catheter so that the infusion will reach the
patient in a timely manner.
yy Consider a pressure bag for the delivery of boluses during
resuscitation.

Catheter Maintenance and Monitoring

yy Clip the hair and perform a sterile preparation.
yy Maintain strict aseptic placement and maintenance
protocols to permit the extended use of the catheter.
yy Place the largest catheter that can be safely and
comfortably used. Very small catheters (24 gauge)
dramatically reduce flow.
yy Flush the catheter q 4 hr unless continuous fluid adminis-
tration is being performed. Research suggests that normal
2013 AAHA

saline is as effective as heparin solutions for this purpose.48

yy If a nonsterile catheter is placed in an emergency setting,
prepare a clean catheter site and insert a new catheter after
TABLE 6 resolution of the emergency.
yy Unwrap the catheter and evaluate the site daily. Aspirate
Relearning What You Thought You Knew*
and flush to check for patency. Replace if the catheter
yy Current recommendations for routine anesthetic fluid rates dressing becomes damp, loosened, or soiled. Inspect
are for 10 mL/kg/hr to avoid adverse effects6,7 for signs of phlebitis, thrombosis, perivascular fluid
yy The use of a K-containing balanced electrolyte solution does administration, infection, or constriction of blood flow
not increase blood K in cats with urethral obstruction51 due to excessively tight bandaging.
yy To minimize the risk of nosocomial infection, the Centers
yy LRS will not exacerbate lactic acidosis52 for Disease Control recommend that fluid administration
yy Patients with subclinical hypertrophic cardiomyopathy may lines be replaced no more than q 4 days.46
be able to tolerate cautious fluid boluses for hypotension if
their volume status is questionable, but they should be closely Conclusion
monitored for fluid overload and congestive heart failure53 Fluid therapy is important for many medical conditions in veterinary
yy LRS or acetated Ringers solution may be used in liver disease. patients. It is dictated by many factors and is highly patient vari-
LRS contains both D- and L-lactate and is unlikely to increase able. Fluid selection for a given patient may change during therapy,
blood lactate levels52 depending on patient needs. The goal of these guidelines is to assist
the clinician in prioritizing goals, selecting appropriate fluids and
yy When flushing an IV catheter, normal saline is as effective as rates of administration, and assessing patient response to therapy.
heparin solution48,54 The reader must recognize the highly individual patient vari-
yy In general, the choice of fluid is less important than the fact that ables and dynamic nature of fluid therapy. Because fluid therapy
it is isotonic. Volume benefits the patient much more than exact can be highly individualized in complex cases, having a relation-
fluid composition. Isotonic fluids wont have a severe negative ship with a referral facility for consultation can be helpful.
impact on most electrolyte imbalances, and their use will begin Ongoing research is challenging current dogma regarding fluid
to bring the bodys fluid composition closer toward normal administration rates, particularly rates for administration during
pending laboratory results that will inform the clinician of more anesthesia (Table 6). There are few evidence-based recommenda-
specific fluid therapy36 tions, and limited research has been performed related to fluid
administration in veterinary patients. The reader is encouraged to
* See text for details. be alert to future data as it becomes available and incorporate that
LRS, lactated Ringers solution. information in practice protocols. n

14
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