Fluid Therapy Part II

7/31/2019 Fluid Therapy Part II

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126|C r i t i c a l C a r e

LectureVI:FluidTherapy

AndrewJRosenfeld,DVMABVP

ElizabethDunphy,DVMAVECC

Thegoalofthischapterisfortheteammembertogetabasicunderstandingofthe

goals of intravenous therapy, how to calculate a fluid rate for the pet, how to monitor

intravenousfluids,andhowtodiscusstreatmentconcernswiththeclient. Administration

orchangestofluidtherapyshouldneverbedonewithoutproperinstructionandconsent

fromtheveterinarian.

It isessentialtohaveawelleducatedhospitalteamthatcanmonitorapatienton

intravenous fluids fordehydration, fluidoverload,and fluid INS/OUTS. Inspecificcases

where there are increased toxins in the blood stream secondary to renal disease, liver

disease,certainformsofdiabetes,orothertoxicorsystemicdiseases;increasedamountsof

fluids

(1

2

x

maintenance)

can

aid

in

removing

toxins

from

the

body

(Diuresis).

The

goal

of fluid maintenance is to provide support to aid in rehydration, maintenance and

possibly diuresis for the pet. Fluid support is the key hallmark for stabilization in a

majorityofemergencycare. Necessarysupplementsanddrugscanbeaddedtothefluid

regimetoaidinthepetsrecovery. NutrientslikeDextroseandPotassium,andmedications

like Metoclopramide, Lidocaine, and Dopamine, can be added to intravenous fluids to

provideacontinuousrateofinfusion(CRI)oftheneededdrug.

Typesoffluidsupport:

Fluidsupportcanbegivenintwoforms,subcutaneousfluidsandintravenousfluids.

Eachtypeofadministrationhasitsownstrengthsandweaknesstohelptheillpatient.

SubcutaneousFluids:

o General: Subcutaneousfluidsareamoderatetolargebolusoffluidsgivenunder

theskintocreateafluidrepositorythatcanbeslowlyabsorbedbythepetovera

36hourperiodoftime.

o Indications:Subcutaneous fluidsaremeant forslowreplenishmentofthemild

tomoderatelydehydratedpatient.Indicationsforutilizationcanbe:

o Acutediseaseproducingmilddehydrationforexample:

MildGastrointestinalDisease

MildUpperRespiratoryInfections


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o ChronicDisease: Subcutaneousfluidsareusedwithpetswithchronicdiseaseat

regular intervalstohelpmaintaintheirhydration. Thesepatientsdiseasesare

usually under control and the pets are eating, drinking and feeling well.

Examplesofchronicdiseasewheresubcutaneousfluidscanbegivenare:

Chronicrenaldisease

Chronicliverdisease

These fluids can be done in the hospital setting, or the owner can be taught to

administersubcutaneousfluidsathome.

Emergency Conditions: Although not as valuable as intravenous fluids in

emergencysituations,subcutaneousfluidscanhelptomildlyrehydrateapatient

thathassevereperfusionproblems. Oncesubcutaneousfluidsareadministered

andabsorbed,aveinmaybemoreeasilycatheterized.

Contraindications: Withproperadministrationofsubcutaneousfluids,thereare

fewcontraindications. Howeversomeconcernsare:

IntravenousFluidAdditives: Somecautionmustbeexercisedthatcertainfluid

additives (i.e.dextrose), whicharenormallygiven intravenously,arenotgiven

subcutaneously. Thesetypesoffluidadditivescancauseirritationanddamage

totheoverlyingskin.

Underlyingdiseaseconditions: Cautionshouldbeexercisedwithpatientsthat

have underlying disease conditions that have the propensity for pulmonary

edema. Although of much less concern then when using intravenous fluids,

repeated subcutaneous fluids may increase the likelihood of buildup of fluid

withinthelungfields. Someoftheseconditionsare:

CongestiveHeartFailure

SevereRenalDisease(EndStage)

Drowning

ElectricCordInjury

Calculation

of

Fluid

Need:

The

veterinarian

will

make

recommendations

for

subcutaneous fluid boluses for the pet. However, the veterinary team should

have an understanding of approximate fluid parameters to prevent

miscommunicationoroveradministrationoffluids(SeeTable6.1).


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Table6.1: GuidelinesforSubcutaneousFluidTherapy

IntravenousFluids

General: Intravenous fluids are one of the hallmark treatments for the

hospitalizedandemergencycarepatients inpractice. Teammembersmustbe

ableto:

Masterevaluatingdehydration

Understand the benefits and concerns with different fluid types (i.e.

crystalloidsvs.colloids)

Understandinghowtocalculatefluidneed

Monitoringapatientonintravenousfluids

Properlydocumentingthefluidadministration

Therearetwolargergroupsofintravenousfluidchoices,theyare:

Crystalloids: Thiscategoryismadeupoftypesoffluidthathaveasimilar

concentration(isotonic)densityasblood. Thegoalofthesefluids isfor

long term intravenous administration for patients needing rehydration,

dieresis,andemergencycare. Examplesofcommonlyusedcrystalloids

are0.9%NaCl,LactatedRingersSolution(LRS),andNormosol

Colloids: Thiscategoryismadeupoffluidtypesthathaveanincreased

density (hypertonic) ascomparedtoblood. These fluidsareseparated

into

two

further

categories,

which

are:

5These fluids are suggestion of fluid ranges based on pets weights. These

ranges are meant for animals without primary disease that could produce

pulmonary edema and congestion (i.e. Congestive Heart Failure, Electric

Cord Injury).

AnimalsWeight ApproxSubcutaneousFluidAmount5


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o Natural Colloids: refer to blood, packed red blood cells and

plasmathataremeantforbloodreplacementproductsinanemic

orbleedinganimals.

o SyntheticColloids: refertohypertonicsolutionsthatareusedfor

shock and emergency patients to help increase systemic blood

pressureorserveasabloodreplacementproduct. (Seebelow).

ApplicationsandadministrationofIntravenousFluidsCrystalloids:

General: Crystalloids are fluids containing electrolyte and non

electrolytesolutescapableofenteringallbody fluidcompartments.

They are the most common form of parenteral (nonoral) fluid

therapy and are classified as replacement solutions (composition

resembling extracellular fluid) or maintenance solutions (See Figure

28.2). The choice of fluid depends upon the disease process. The

most useful crystalloid solutions for routine use are balanced

replacementsolutionssuchasRingersorLactatedRingersSolution,

NormosolR,0.9%Salineand5%dextroseinwater.

Indications: Crystalloid fluids are indicated for the treatment of ill

patients that need rehydration, dieresis, or emergency care.

Intravenoussupportcanbegivenoverhourstodayssafely. Nutrients

such as dextrose and potassium chloride can be added to fluids to

help provide minimal nutritional support as well as balance

electrolytes. Further,drugs(suchasMetoclopramideandLidocaine)

can be given for continuous administration (CRI continuous rate

infusion)ofthesickpatient.

Contraindications: Since intravenous fluidsprovideaconstant flow

of liquid directly into the vein, caution must be exercised with

patients with specific diseases. Careful monitoring is necessary for

patientswithunderlyingdiseaseconditionsthathavethepropensity

toproducepulmonary edema. Sincethesepetscannotcontrolthe

rate

at

which

fluids

enter

their

body,

the

patients

can

become

over

hydrated and begin building up fluid within the lung tissue

(pulmonarycongestion). Somediseasesthatrequirecautionare:

CongestiveHeartFailure

SevereRenalDisease(EndStage)

DrowningElectricCordInjury


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Further, animals that have diseases producing profound anemia or

blood loss can be made worse with high volumes of intravenous

fluids. These patients do not have enough red blood cells to carry

oxygen

to

the

body.

If

too

much

intravenous

fluids

are

administered,

the blood can become more dilute decreasing its oxygen carrying

capacity. Somepotentialdiseaseproducingaseriousacuteorchronic

anemia:

ChronicRenalDisease(SeeChapterXIII)

ChronicLiverDisease(SeeChapterXIV)

BloodLoss/Trauma(SeeChapterXXX)

AutoimmuneHemolyticAnemia

CalculationofFluidNeed:

General: Calculationoffluidneedisdependenton:

Thepet

Thedisease

Fluidlosses(i.e.diarrheaandvomiting)

Thepetslevelofdehydration

Ifthepetisinshock

The treatment amounts are up to the veterinarians recommendations. However, the

team member must have a concept of the type, the daily fluid needsand rates of fluids

given inordertomakesurethepet isgettinganadequateamountoffluidstorehydrate

whilenotoverloading. Thecategoriesforrehydrationareasfollows:

Maintenance: Maintenance fluids are the minimum amount of fluids needed

giventoapetthatisnothavingsignificantfluidlosses(i.e.vomitingordiarrhea)

tomaintainnormalhydration. Allanimalsrequire66ml/kg/dayfluidsforthe

bodytofunctionnormally.

Maintenance=BW

(kg)

x66

ml/

kg/

day

Dehydration: Dehydrationisaqualitativemeasurementofdehydrationlevelof

the patient based on skin turgor, gums, eye appearance, and / or packed cell

volume. AsdiscussedinChapterVI,dehydrationisbasedonthefollowingscale:


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03%: Undetectable dehydration secondary to an animal that has been

vomitingorhavingmilddiarrhea.

57%:

Beginning

of

detectable

dehydration

with

slight

decrease

in

skin

turgorandbeginningofdrygums.

79%:ismoreperceivabledehydrationwithmuchmoredecreasedelasticity

ofskin,drygumsandsunkeneyes.

912%:Lifethreateningdehydrationwithnoelasticityofskin,sunkeneyes,

drygums,depressionandweakness.

Calculatingfordehydrationusesthefollowingformula:

Dehydration=%Dehydratedindecimalform x wt(kg)*1000ml/l

Hourly fluid rate: Hourly fluid rate is calculated by taking total fluid need and

dividingby24hrs/day. Formula:

HourlyFluidRate=(TotalFluidNeed/day) / (24hours/day)

BolusingFluids:

Intimesofseveredehydration,priortoasurgeryortreatment,the

doctor may want to give an intravenous bolus to help recap the fluid loss more

quickly.Thereisnospecificamountoffluidsadministered;however,ageneralguide

forbolusingpatientscanbe10 20%oftotalfluidforthatday.Theoverallbolusis

subtracted from total fluid need and then hourly fluid rate is calculated. When

bolusingfluids,thepatientmustbemonitoredforfluidoverload(seebelow).

Tocalculatedropspersecond:

Drops/Second=mls/second x drops/mls(dripsystem)

ChronicityStrip: Oncedrops/secondiscalculated,achronicitystripcanbeusedto

makesuretheanimalshourlyneedsarebeingcalculated(SeeFigure28.3).Thistype

ofstrip,usuallymadeof1inchwhitetape,isplacedonabagoffluidsandthetimes

are correlated with what the estimated fluid levels should be at that given time.

Thisallowsthetechniciantheabilitytoadjustthefluidrateasitischeckedevery12

hours.


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SelectingIVFluidCare:

FluidType Indicationsforuse Contraindications

0.9%NaClRehydration,Diuresis,

andMaintenance

AcidoticPatients

(Addisonians,Metabolic

AcidosisPatients

LRS(Lactated

Ringer

Solution)

Rehydration,Diuresis,

andMaintenance,

HypocalcemiaPatient

LiverPatient

Normosol /

Plasmalyte

Rehydration,Diuresis,

andMaintenance

0.45NaCl&5%

Dextrose

Fluidsupportofthe

cardiacpatientHYPOTENSION


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IVFluidAdministrationAlgorithm

Step I: Maintenance Fluids:

______Wt (kg) * 66 ml/kg/day = ________ ml/ day

Step II: Dehydration:

______Wt (kg) * ____% Deny * 1

Step III: Total Fluid Need (TFN)

TFN = Maintenance = Dehydration

Step III a: Bolus:

Bolus = TFN * 0.2

Step III b: recalculate TFN

NEW TFN = TFN - Bolus

WithFluidBolus

Step IV: Hourly Rate (HR)

Hourly Rate = TFN / 24 hrs

WithoutFluidBolus

St

m

Se

D


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Fluid Therapy for Shock: There are times when an animal is in a life threatening condition,

shock,orcardiovascularshutdownwhenEmergencyFluidDosemayneedtobegiven. Atthis

time,thispatientneedshighfluidvolumestomaintaintheirbloodpressureandcardiacoutput.

Emergency dose of fluids are not associated or subtracted from daily need, they are given

until

normal

perfusion

and

cardiac

output

are

returned

and

the

patient

is

no

longer

in

shock.

Generalguidelinesforemergencybolusesare:

Dogs:90ml/kg/hr*wt(kg)

Cats: 45ml/kg/hr*wt(kg)

Duetothelifethreateningemergency,thesefluidsaregivenasquicklyaspossible,oftenwitha

highpressurebagtomaximizefluidadministration(SeeFigure28.4).

Itimportanttounderstandthattheseshockdosesrepresentthemaximumamountoffluidsa

healthypetcanreceivein1hourbeforefluidbeginstobuildupwithinthetissue. Thereare

many patients that cannot tolerate these large doses, and the animal must be closely

monitoredforfluidoverloadwhileshockdosesarebeingadministered.

Once the pet is stabilized, it is reevaluated by the veterinarian and hourly fluid rate is

reassigneddependentondehydration,medicaldisease,andcurrentphysicalcondition. Please

refertotable28.2foraroughoverviewoffluidneedbasedonthepatientsphysicalcondition.


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Estimationoffluidadministrationneeddependentonhydrationandfluidlossstatus6

Species Condition

Significant

V/D

Suggested Fluid Administration

Level

Feline&Canine 05 % Dehydrated /Stable

N Maintenance > 1 x

Maintenance

Feline&Canine 05 % Dehydrated /Stable

Y Bolus+1 2x/Maintenance

Feline&Canine 7 9 % Dehydrated /Stable

N Bolus + Maintenance> 1 x

Maintenance

Feline&Canine 7 9 % Dehydrated /Stable

Y Bolus+2xMaintenance

Feline&Canine 912 %Dehydrated /Stable N Bolus+2xMaintenance

Feline&Canine 912% Dehydrated /Stable

Y Bolus+2x/Maintenance

Feline Unstable YorN ShockFluidDoses(45ml/kg/hr)Canine Unstable YorN ShockFluidDoses(90ml/kg/hr)

6 This table is a rough estimate of fluid need and should be only used as a reference source for the

medical team member to ascertain the relative fluid level needed for a sick patient. All fluid

administration rates are based solely on the veterinarian recommendations.


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Complications Fluid Overload refers to the situation when an animal is receiving too many

intravenousfluidsorreceiving fluids too quickly. If too much fluid is given, the excess

fluidcanbegintopooloutsideofthevesselsandproducefluidbuildupinthetissue. Ifenough

fluid

accumulates

in

the

lungs,

the

pet

can

drown.

Signs

of

fluid

overload:

Clearnasaldischargeasfluidsarebeinggiven.

Lickinglips

Actingnauseous

Fluidbuildupinfeetunderneckedema.

Increasedrespiratoryeffortandrespiratorycracklesareevident.

ApplicationsandadministrationofIntravenousFluidsColloids:

General:

Colloids are large macromolecular synthetic solutions (i.e. Hetastarch,

Pentastarch)ornaturalsolutions(i.e.Blood,Plasma,PackedRedBloodCells)are

used in the treatment of shock and the maintenance of intravascular fluid

balance.

Theselargedensemoleculesenterthebloodvesselsandincreasetheamountof

fluiddrawnintothevesselsandresultinanincreasedbloodpressure. .

Reducethe

total

fluid

need

of

the

patient

by

40

60%.

Therearetwocategoriesofcolloids:NaturalandSynthetic

Naturalcolloidsincludewholeblood,plasmaproductsandalbumin.

Syntheticcolloidsareformulatedfromvarioussources,suchasgelatins,

polysaccharides(dextrans)oramylopectins(Hetastarch).

Pharmacologicclassificationisbaseduponmolecularweight,plasmahalflifeand

colloidoncoticpressure. Eachcolloidsolutionwithinthesegroupshasspecificcharacteristics, qualities and side effects, which must be considered in the

selectionoftheappropriatetherapyforeachpatient.

Indications: Colloidscanservetwooverallfunctions:


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To increasefluiduptakeintothevesselsfromthetissue increasingbloodpressure.

Thecolloidsgenerallyusedforthisfunctionare:

Hetastarch

Pentastarch

To replace necessary blood factors needed for oxygenation of tissue, clotting of

bloodandwoundhealing. Thecolloidsusedforthisfunctionare:

PackedRedBloodCells:Servesasasourceofredbloodcellstohelpthepatient

increasetheirpackedcellvolumeand increasetheoxygencarryingcapacityof

theirblood.

Plasma: is the fluid portion of blood whichcarries theproteins necessary for

clotting blood. Further, plasma is rich in a protein called albumin, which

maintains blood pressure by drawing water into the blood vessels as well.

Withoutproperlevelsofalbumenintheblood,fluidcanpoolintotissuecausing

edemaanddecreasingbloodpressure. Further,albuminisakeyproteinintissue

healing.

Contraindications: Each of these colloidshas their own limitationsdependenton

thepatientscondition. Themaincontraindicationsare:

Allergic Reaction: These chemicals can produce moderate to severe allergicreactioninthepet,andshouldalwaysbeadministeredslowlyinahospitalizedsituation.

Dehydration: Further, since these drugs function also to pull fluid into the

vascular supply, the pet must be reasonably hydrated before administration.

Givingcolloidstoadehydratedanimalcanleadtofurtherdehydrationandpoor

circulationas thebody is unable to move these largermolecules to the blood

stream.

Calculation of Fluid Need: The only colloid that will be discussed for calculation

information is Hetastarch. Hetastarch is given in emergency cases when normal

intravenous

fluids

are

not

returning

normal

perfusion

and

strong

pulses

to

the

shocky patient. As with all other fluid calculations, recommendations for fluid

administrationaremadebytheveterinarian. However,inanemergencysituation,

themedicalstaffshouldhaveanunderstandingoftheneedspatientandanticipated

theveterinariantobereadytobegintreatmentofalifethreatenedpet.


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ColloidType Reason Dose Concerns

Hetastarch HypotensionFeline:11 15ml/kg/day

Canine:1122ml/kg/day

AllergicReaction

CoreDehydration

Tissue3rd

Spacing

Plasma ClottingFactors 1unit/20pounds AllergicReaction

Plasma Hypoalbunemia45ml/kgtoraiseAlbumin

1.0gm/dlAllergicReaction

WholeBlood ActiveBleeding 1cc/lbtoraisePCV1%AllergicReaction

Hemolysis

PackedRedBloodCells Anemia/Bleeding1cc/poundtoraisePCV

1.5%

AllergicReaction

Hemolysis

Complications: Colloidscanproducemildtosevereallergic/ anaphylactic

reactions to administration. Patients should be always maintained in a hospital

settingunderdirectsupervision. Fluidsshouldbegivenslowlyinitiallytomakesure

thepet isnothavinganyseverereaction,especially infelines.Although,this isan

uncommon

complication,

the

pet

must

be

closely

monitored

for:

Increasingdehydration

IncreasedRespiratoryEffort

IncreasingHeart/PulseRate

Palingofthemucusmembranes


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RespiratoryWheezing

DecreasedMentation/Responsivity

LateralorSternalRecumbence

Collapse

CardiopulmonaryArrest(SevereCases)

Administration:

Hetastarch can be administrated by a number of procedures. Two possible

procedurescanbe:

Smallpatient(

Dosages(Oneofthefollowing):

1) Volumetobetransfused=

90ml(dog)or60ml(cat)X Recipient.BW(kg)X(DesiredPCVActualPCV)

Donor'sPCV

2) 1225ml/kg

3) 2ml/kgwholebloodwithPCV40%willraiserecipienthematocrit1%


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4) 1.0mlbloodper1lbrecipientweightwillraisePCVby1%

Rate of administration: Start all transfusions at 0.25 ml/kg for first 15

minutes

to

monitor

for

any

transfusion

reactions.

Thereafter

the

rate

can

beincreasedto510ml/kg/hr,Bloodproductsshouldnotbegivenover

morethan4hoursthough andmostpeoplesimplycalculatetherateof

administrationbydividingthetotalvolumeneededby3or4hours.Care

mustbetakenwiththosepatientsthatareatriskforfluidoverload.The

maximumrateforsuchpatientsis4/mlIkglhr.

Storage:Canineand felineRBCsareviable for34weeksdependingon

theanticoagulantused. Wholebloodmustberefrigerated.

Packedred

blood

cells

(PRBC)Packedredbloodcellsare indicatedforanemiadueto

bloodloss,hemolysis,andbonemarrowdysfunction.

o Dosage:610ml/kg.

o Rate of administration: Same as for all blood products. Start slowly at 0.25

ml/kg/hrforthefirsthourandthenincreaseto510ml/kg/hr.

o Storage:ThestorageofPRBCisthesameasthatforwholeblood.PRBCmustbe

refrigeratedandareviableforapproximately3to4weeks.

Plasma Fresh Frozen Plasma: Plasma transfusions are used to replace hemostatic

proteins, namely the clotting factors, von Willebrands factor and fibrogen and

fibronectin.Theproductsusedtoreplacehemostaticproteinsare:

o FreshFrozenPlasma istypicallyusedasasourceofclottingfactors.Indications

include hepatic dysfunction, anticoagulant rodenticide toxicity, hemophilia B,

vonWillebrand'sdeficiencyandhemophiliaA(cryoprecipitateisabetterchoice

though),andDIC.


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FFPisnotareasonablechoicetoreplacealbuminthoughasthevolume

ofplasmarequiredtocauseasignificantaffectonproteincounts isnot

practical.Ittakes45ml/kgtoraisealbumin11g/dl.

Dosage:

610

ml/kg

Rate of administration: Similar to all blood products, start at 0.25

ml/kg/hrtomonitorfortransfusionreactionsandthen increaseto510

ml/kg/hr. As with PRBC, plasma should not be delivered over greater

than4hours.

Storage:FFPcanbestoredat 20DegreeCelsiusfor1year.

Cryoprecipitate:

Indicated in Hemophilia A, von Willebrand's Disease, generalized

sepsis,DICandfibrinogendeficiency.TheadvantageofcryoprecipitateoverFFPisthat

itsuserequiresamuchlowervolume,whichminimizestheriskofvolumeoverload.

Dosage:1unit/10kgevery12hoursasneeded

Storage:Canbestoredat 20degreesCelsiusforupto1year.

Cryosupernatant: Indications for use the same as FFP with the exception of von

Willebrand's disease, hemophilia and fibrinogen deficiency, as these factors are

removedwiththecryoprecipitate.

o Dosage:610ml/kg

o Rateofadministration: Similartoallbloodproducts,startat0.25ml/kg/hrto

monitor for transfusion reactionsand then increase to510m1/kg/hr.Aswith

PRBC,plasmashouldnotbedeliveredovergreaterthan4hours.

o Storage:Cryosupernatantcanbestoredat 20DegreeCelsiusfor1year;


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ReplacementofPlatelets:Thereplacementofplateletsisverydifficulttosaytheleast.

Itisnotdoneveryfrequentlysincethemajorcauseofthrombocytopeniainveterinary

patients is Immune Mediated Thrombocytopenia and the transfused platelets are

quicklydestroyed.Inaddition,theclinicalsignsofbleedingdonotusuallyoccurunless

plateletcountisbelow50,000.Ifthehematocritisstableandanybleedingconsidered

minimalthanthetransfusionofplateletsisrarelyindicated. Transfusingplateletsmay

beindicatedpriortoasurgicalprocedure,ifanintracranialbleedissuspected,orwith

plateletfunctiondefectssuchasNSAIDoverdose.Iftransfusingplateletsisdesired,than

therearetwoavailablebloodproducts.

o PlateletRichPlasma/PlateletConcentrateDosage:

PRP610ml/kg

PC1unit/10kg

Platelet Phoresis is now a source of platelets. This process is able to greatly

concentrateplateletssothat>1millionplateletsaretransfused.Theproductis

veryexpensiveandcurrentlyneedstobeshippedinfromMidwestAnimalBlood

Services.

CrossmatchingandTransfusionReactions

Blood types: Blood types are genetic markers on the erythrocyte surface that are

antigenicandspeciesspecific.

Dogs:

Dogsdonothavetruebloodtypesasthetermisusedforhumansandcats.

The dog instead has Dog Erythrocyte Antigens (DEA), which are numbered

1.1,1.2,3,4,5,6,7,8.Clinicallythemostimportantare1.1,1.2andpossibly

7.Dogscanbe1.1positiveornegative.

IfDEA1.1negative,theycanthenbeDEA1.2positiveornegative.DEA1.1is

stronglyantigenic.AfirsttimetransfusionofDEA1.1positivebloodtoaDEA

1.1negativedogwillelicitastrongalloantibodyresponse.


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These alloantibodies may not develop for up to 4 days and can cause a

delayedtransfusionreaction.Apreviouslysensitizeddogcanhaveanacute

hemolyticreaction.

Cats:

Likeeverythingelseinmedicine,catsaredifferentfromdogs.Catshaveonly

3bloodtypes,ABandAB.

These blood types have a unique inheritance pattern. The A allele is

dominanttoBallele.TypeAcatsareeitherA/AorA/B.TypeBcatsmustbe

B/B,ABisveryrareandinvolvestheinheritanceofa3rdallele.IntheUnited

States

Type

A

is

the

most

common;

the

frequency

of

type

A

vs.

B

cats

varies

amongbreedsandgeographicalregions.

In contrast to dogs cats have naturally occurringalloantibodies against the

bloodtypeantigenthey lack, i.e.donotneedtobesensitized.TypeBcats

haveverystronganti~Aantibodies.

A transfusionofTypeA blood toa TypeB catwill result inaveryserious,

acute hemolytic reaction, usually fatal. Cats can also have neonatal

isoerythrolysis. (AI AB kittens receiving antiA antibodies from a type B

mom'scolostrum.).


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Blood typing techniques: In house cards are available that type dogs as DEA 1.1

positiveornegativeaswellascardsthattypecatsasA,B,ABpositiveornegative.Blood

canbesentouttospecializedlabstotypedogsDEA1.1,1.2,3,4,5,and7

Crossmatching:

Crossmatchingindicatestheserologiccompatibilityorincompatibilitybetweenthe

donorandtherecipient.Alloantibodiescanbehemolyzingorhemoagglutinating.

Amajorcrossmatchmeasuresalloantibodies intherecipient'splasmaagainst the

donor's cells. A minor cross match measures alloantibodies in the donor's plasma

againsttherecipient'scells,

A previously transfused dog must have a crossmatch prior to an additional

transfusion.Antibodies

can

be

induced

as

quickly

as

4days

and

can

be

present

for

years.Adogthathastrulyneverbeentransfusedpotentiallycanskipacrossmatch

butabloodtypeshouldbedone.

Cats must be typed or crossmatched even on the first transfusion because of

naturallyoccurringalloantibodies.

AdministrationTechniques: Whenadministeringanycolloid,ahospitalprotocolshouldbeset

upforadministrationofthefluid. Althoughhospitalsdiffer,onesuggestedprotocolis

1. Maintain

IV

Fluids

while

a

transfusion

is

being

given: Maintaining IV fluids help to

maintainhydrationanddecreasethelikelihoodoftransfusionreaction. Furtheritallows

aportformedicationifneeded.

2. Premedicate the patient: If the patient is set for receiving a natural colloid (blood,plasma,packedRBC)manyteamswillpremedicatepatientwithdiphenhydramine.

3. Set a secondary IV catheter and begin transfusion of colloid: Have a teammember

evaluatetheanimalevery5minutesforthe first3060minuteswhileatransfusion is

being

given.

Each

time

the

patients

vitals

are

recorded

and

the

patient

is

checked

for:

a. IncreasingHeartRate

b. DecreasingPulseQuality

c. Panting


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d. IncreaseinBodyTemperature

e. IncreaseinRespiratoryrate

f. ChangeinMentation

Ifnoted,thetransfusionistemporarilystoppedandtheveterinarianiscontacted

immediately. Manytimesfluidrateswilloftenjustbeslowed.

4. If transfusing whole blood or packed RBC: Team membersshould recheckPCV /TP

when the transfusion is 50% completed. In some cases the animals PCV will

dramatically increase above expected goals and to prevent colloid overload, the

transfusionmayneedtobeslowedorstopped. Serumcolorshouldbeevaluated for

hemolysisaswell.

5. Continuethetransfusionoverthenext3hours: Ifnoreactionisnotedatthispoint,the

transfusion rate should be continued over the next 3 hours. Team members should

monitorthispatientevery1015minutesuntilthetransfusioniscompleted.

6. If transfusing whole blood or packed RBC: Team membersshould recheckPCV /TP

whenthetransfusion iscompletedtoevaluatefinaleffectoftransfusionandtosee if

othertransfusionsmayberequiredinthefuture. Serumcolorshouldbeevaluatedfor

hemolysisaswell.

Transfusionreactions:

Hemolysis

Urticaria/edema

Hypotension

Treatment consists of immediately stopping the transfusion and administering short

actingcorticosteroidsand/ordiphenhydramine.Seriousreactionsmayrequiretreating

withepinephrine.


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Nonimmunemediatedreactionsareusuallycausedbyhumanerror.Theseinclude:

Circulatoryoverload

Sepsisfromcontaminatedproduct

Hypocalcemia

Hemolysisfromcontactwithhypotonicsolutions

Agglutinationfromcontactwithcalciumcontainingsolutions

Diseasetransmission(Heartworm,Babesia,Hemobart,Ehrlichia,FELV,FIV)

BloodCollection

and

Donor

Selection

AnticoagulantsCitrateactsasananticoagulantbyinhibitingcalciumdependentstepsof

theclottingcascade,otheradditivesincludebuffersandredbloodcellenergysources.

The2mostcommonanticoagulantsusedare:

Citratephosphatedextroseadenine(CPDA): Usea1:9dilution,meaningadd1

m1ofCPDAforevery9m1ofblood.WithCPDAcanineRBCsareviableforupto

4weeks

Acidcitratedextrose (ACD): Usea1:6dilution,meaningadd1m1of ACD for

every6m1ofblood.WithACDcanineRBCsareviableupto3weeksandfeline

RBCsareviableupto30days,

CanineDonors:Theirweightshouldideallybegreaterthan25kgandtheirageideally2

8yearsold. Thehematocritneedstobe>40%. Thedogsneedtobehealthyandfree

frombloodbornediseaseswithaknownbloodtype. Ideally1.1,1.2and7shouldbe

determined.FinallythedogsshouldhaveaknownvonWillebrandsfactorstatus

Collection technique: Thejugular vein ispreferred for blood collection.Sterile

techniques must be employed. The maximum donation for any one donor is


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22ml/kgevery34weeks.Replacementfluidsarenecessaryifmorethan5%ofa

donor'sbloodvolumeisdonated.Theuseofacommercialtriplepackcollection

system is preferred. These bags contain the anticoagulant CPDA and a RBC

nutritionsourcealreadyadded

Feline:Theirweightshouldbegreaterthan5kgandtheiragebetween2and8years

old.Thehematocritneedstobegreaterthan30%.Thecatsneedtobehealthyandfree

frombloodbornediseasewithaknownbloodtype.

Collection technique: Sedation is usually required when drawing blood from a

donorcat.Asindogs,the betakerfromanyonedonoris15m/kgevery4weeks.

NEVERtakemorethan60mlatonetimefromadonorcat.Frequentlythedose

neededforthepatientisgreaterthan60ml,butunlessitisaverylargecat,60

m1 isthemaximumamountacatcansafelydonateatonetime.Replacement

fluidsarenecessaryifmorethan5%ofdonor'sbodyweightisdonated.

Fluid Therapy Part II

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