Whilst sub-Qs are not always necessary or appropriate (see below), most
CKD cats do eventually end up needing them. See
Subcutaneous Fluids
for the criteria for deciding when sub-Qs are likely to be necessary.
If you live in the USA or Canada, where sub-Q fluids are a mainstream
treatment, you are unlikely to need this page because you will most
probably be offered sub-Qs. If you live anywhere else, you probably will
need it.
Much of the information here is geared towards the UK because that's
where most of the complaints I receive about this issue come from, but
hopefully the suggestions will be helpful wherever you live.
In many ways, fluid therapy in the form of subcutaneous fluids
(hereafter referred to as sub-Qs, but usually known as sub-cuts in
the UK), is the raison d'être for this website. I am absolutely
certain that Thomas would have died back in January 2000 without
sub-Qs - yet sadly, they are a very rare treatment in most parts of
the world apart from Canada and the USA. The quotation above
expresses very clearly my hopes for the use of subcutaneous fluids
gradually becoming a standard treatment for CKD cats throughout the world.
I have been told that in Denmark it is actually illegal for a layperson
to give sub-Qs at home to a cat. I don't know if this is true, but I've
heard this from several sources, so it might well be. Other European
countries where it can be particularly hard to win your vet over are
Sweden and the Netherlands. Most of the other European countries are on
a par with the UK. i.e. you won't be offered sub-Qs routinely, and your
vet will resist allowing you to use them if you ask, although if you are
lucky enough to live in Germany, you may find obtaining sub-Qs less
difficult.
11 guidelines for conservatively treating chronic kidney
disease (2007) Polzin D, Veterinary
MedicineDecember 2007, Dr Polzin states "The
clinical consequences of chronic dehydration include decreased appetite,
lethargy, weakness, constipation, prerenal azotemia, and predisposition to
acute kidney injury. Additional loss of kidney function due to acute kidney
injury is a potentially important cause of progression of chronic kidney
disease." In other words, untreated dehydration can at best make your cat feel
lousy and at worst may make the CKD progress faster.
Powerful stuff. Yet in the UK, your vet will almost certainly resist the idea
of you giving sub-Qs at home.
British vets certainly know about sub-Qs and use them themselves
when appropriate; yet they do not routinely offer them to clients for home
use. Having lived in both the UK and the USA, where sub-Qs are
considered to be a routine treatment, I do think this is partly down to
cultural differences. The UK approach is geared towards what are
perceived to be the cat's needs rather than the client's. This can
actually be a good thing for cats: UK vets would never declaw a cat, for
example, because it is considered of no benefit to the cat and is
therefore illegal. Unfortunately, this may then cross over into the UK
vet's approach to fluids: they think sub-Qs are quite simply a step too
far, and painful and unfair on the cat, so they refuse to allow them.
Let's take a look at the usual objections I've heard of over the years
and the counter arguments you can use if appropriate.
"Subcuts are not necessary"
They may not be necessary if your cat can drink enough to maintain
hydration. Unfortunately, cats whose creatinine levels are
consistently over 300-350 (US: 3.5-4), which equates to high Stage 3
of the IRIS staging system, can usually no longer drink enough. You may
be able to add water to your cat's food, or syringe small amounts of
water in to your cat's mouth, but eventually most CKD cats do need
sub-Qs.
"If your cat gets dehydrated, we'll use intravenous fluids"
Certainly IV fluids are a great way to rehydrate a CKD cat. Sometimes
they are essential because if a cat becomes severely dehydrated, sub-Qs
may not be effective because the dehydration prevents them being
absorbed properly. However,
IV fluids are also expensive for you and stressful for your cat who has to be hospitalised to receive them. Many cats don't eat when in hospital, not
ideal for CKD cats who tend to be thin and have a poor appetite anyway.
Therefore it is better to reserve
IV fluids for a crisis situation
(crashing).
The primary purpose of sub-Qs is to avoid dehydration, which
reduces the risk of your cat crashing and needing IV fluids in the first
place.
"Subcuts are painful"
The whole point of giving sub-Qs is to avoid dehydration, which will
make your cat more comfortable. Dehydration feels like a bad hangover or
the flu. Would you like to spend a couple of weeks feeling progressively
more ill as you develop dehydration which steadily worsens, then be
hospitalised for IV fluids; or would you prefer to receive an at home
treatment that takes just five minutes a day and prevents the
dehydration occurring in the first place?
In terms of technique, sub-Qs probably are painful if you use thick
"kitty harpoons" for needles. And they certainly won't be pleasant if
you follow commonly issued advice in the UK from those rare vets who
permit you to use sub-Qs but who unfortunately recommend injecting 10ml of fluid
into your cat ten times, rather than giving 100ml in one place with only
one needle stick. Multiple sticks are not necessary:
Colorado State University College of Veterinary
Medicine states "no more than 5 to 10
ml/lb should be given at each injection site" so giving 100ml in one place
should not be a problem for a 10lb cat.
There are many ways to make the whole experience far more comfortable
for your cat, and if you use the tips and techniques on this site,
you should be fine. I have heard of several cats who actually come and
ask for their sub-Qs if their human is late giving them. I don't think
most cats are masochists who freely seek out painful experiences, so I
think it's reasonable to conclude that the cats do not find the sub-Qs
painful when they are done correctly.
"They are not effective"
This really depends upon what is meant by "effective." They
are not the best choice for cats with kidney stones who need an IV
flush. Sub-Qs are not appropriate for a cat in bad shape who has
crashed and who
would benefit from intravenous fluids instead. However, the whole
purpose of sub-Qs is to keep your cat hydrated so a crash is less likely
to happen. Most of the cats on the
Success Stories
page - some of whom lived for years with CKD - received regular sub-Q
fluids.
"They are too expensive"
I suppose they might be if your vet charges you a lot for your supplies.
There are two other possibilities: the vet gives you a break on the
price, or gives you a prescription so you can buy your supplies online
cheaply.
"They cause infection or scar tissue"
In twelve years of hearing about literally thousands of cats receiving
sub-Qs regularly, I can only recall a couple of cases of infection.
These were mild, localised infections which responded well to a short course of
antibiotics.
Scar tissue is a potential risk, but if you rotate the area where you
give sub-Qs, and don't use the strange British approach of giving up to
ten needle sticks a day simply to give 100ml, the risks are very low. I
know of people who have given sub-Qs for seven years who have not had
problems with scar tissue.
"The only way I will agree to this is by inserting a catheter under anaesthetic"
Some vets are so convinced that sub-Qs are painful that they will only
consider them if the cat is given a fluid port. There is information
about these devices
here, but they have a lot of downsides apart from
the need for anaesthesia: they cost a lot to insert and to maintain,
they can irritate the cat, they are prone to infection and often fail.
It's also not really possible to let a cat with a catheter go outside,
and if your cat is like Thomas, this would be removing a major source of
pleasure from your cat. I don't understand why UK vets seriously
consider this extremely invasive approach to be a reasonable alternative
to sub-Qs with a needle. Isn't five minutes treatment a day with a
needle a better choice than a permanent foreign body poking out of your
cat?
"Your cat does not need fluids"
If your cat has crashed and been on IV fluids for a particular reason,
such as a kidney stone, or to treat an infection, once the crisis is
over your cat may perhaps not need ongoing sub-Qs. Similarly, a cat who has
acute kidney
injury may sometimes make a complete recovery and not need sub-Qs.
Most cats with creatinine in IRIS Stage 3 will
need sub-Qs in order to remain adequately hydrated.
"They are not appropriate for your cat"
This might well be true. They are not the best choice for cats with
kidney stones who need an IV flush, though sub-Qs may be needed
afterwards. IV fluids would also be more appropriate for a cat who has
crashed. Sub-Qs are not a benign treatment, and can be
risky for cats with concurrent heart disease. Please see
below for when
sub-Qs might not be appropriate.
"Your cat could not cope" or "You'll ruin your relationship with your
cat"
Your
vet is correct that you need to take your cat's personality into
account. Some cats might not cope with sub-Qs. Most do. It's hard to
know until you try.
"You can't trust what you read on the internet"
Your vet is quite right. There are some dreadful websites out there. I
try to keep this one as accurate as possible, but I'm not a vet, so your
vet may remain sceptical. In these cases it may help to show your vet
some veterinary websites on the subject (see
below).
The good news is it's not completely hopeless. Every year I hear from
people whose vets have reluctantly agreed to them trying sub-Qs, and who
are now complete converts, having seen how effective they are.
So, if your vet is sceptical about the idea, how do you persuade them to
let you try? Well, in certain circumstances as discussed
below, fluids
are not an appropriate treatment, so first try to ascertain whether in
fact your vet has legitimate concerns and objections.
Next, you're going to have to negotiate. It's a scary word, but it just
takes a bit of determination, a bit of practice, and remember the main
goal: everybody has to leave the table happy. In any negotiation though,
one party is probably happier than the other, and in this case we need
this to be you. But that's OK, because you have so much more to lose:
your vet might feel slightly driven into a corner by your demands, but
you are facing losing your beloved cat. No contest really, is it. There
is not much you can offer your vet in return for allowing you to do
sub-Qs, but if you can reassure him/her that you have your cat's best
interests at heart, say you will not continue with the sub-Qs if your
cat really hates them, and suggest a fixed trial period (say 4-6 weeks),
your vet may be prepared to compromise.
Please do not be rude to your vet. Your vet has extensive training and
experience, and these should not be lightly dismissed. You are not
trying to teach your vet how to do his/her job. However, vets encounter
many different species and many different illnesses every day, and
cannot possibly be expected to keep up to date on the latest
developments for every illness and
every species. You are in a far better position to do research, because
all your efforts are invested in one particular family member, your cat,
with one particular illness. So ask, don't demand. Explain that you wish
to be partners in your cat's care. Try to make things easy for your vet. Marshall your thoughts, take some research along to support your request
(see below). Most vets who are confident in their abilities
may still think you are misguided but will welcome the opportunity to
discuss and negotiate. Less confident ones may feel challenged.
Assuming there is no valid reason for not giving your cat fluids, these
are some of the arguments you could use:
Make it clear to your vet that you are very
committed to your cat's wellbeing and that you wish to play your part
and be proactive in treating your cat. My vet mentioned that in her
experience very few
people are prepared to go to such lengths for their cat: so ensure
your vet knows that you are such a person.
One thing
that I think helped persuade my vet to let me give sub-Qs was when I
explained to her that I knew we might not be able to save Thomas, but
that it would help me personally to know I had done all I could for
him.
If your vet believes that sub-Qs will not
help your cat, but concedes that they also will not hurt your cat,
would he/she be prepared for you to use them for 4-6 weeks, so you can
both see if they do in fact help? It is your time and money being used
so the vet does not really have any valid reasons for objection on
these grounds.
If your vet feels sub-Q treatment is too invasive,
ask whether your vet objects to clients giving their cats insulin
objections? If not, politely ask what really is the difference between
twice daily insulin injections and regular sub-Q injections?
5.
If your vet says sub-Qs are painful, ask on what
this opinion is based. My vet agreed to me giving fluids because she believed that the sensation of the fluid going under
the skin might feel a little strange, but she did not think
they were painful. Unfortunately many UK vets do genuinely believe
that sub-Qs are painful and stressful if given regularly, not least
because few UK vets have any
experience of sub-Qs being used on a regular basis. Look at Cookie
(left) - does he look like he is in pain? Does he look traumatised? My Thomas did not fight fluids at all, he did not
cry, he just sat quietly, and it was all over in under five minutes a
session, as the photos in
How to Give
Subcutaneous Fluids: Syringe Method show. Here are some great photos of
Shelly's cats
(click on We Love Kitty Stickems if necessary)
and
Judi's Hobbes
receiving fluids with no problems at all.
Fluids: the Film is a video of a CKD cat,
Darla, receiving fluids. This shows a cat who is not at all bothered
by the process; perhaps ask your vet to watch it.
Some vets think that sub-Qs are painful because they
entail multiple injections, but if you give fluids the way we did or
use a giving set as most Americans do, it is only necessary to insert
the needle into the cat
once in each session. It is also extremely
important to use Terumo needles: these are incredibly sharp and slide in so smoothly, there is
no comparison with other needles. See
Tips on
Giving
Subcutaneous Fluids for
more information on Terumos.
if your vet says that receiving fluids regularly
could distress your cat, point out that in return for a mere 10
minutes a day treatment, your cat will receive a much better quality
of life for the other 23 hours and 50 minutes in the day. If I had really
thought that receiving fluids distressed Thomas, I doubt I could have
brought
myself to administer them; but they simply did not. Look at the pictures of Thomas being given his
fluids in
How to Give
Subcutaneous Fluids: Syringe Method and Purr Box being given her
fluids in
How to Give
Subcutaneous Fluids: Giving Set Method - you can see they are not distressed in any way.
Since I am a layperson, and since the internet is full of unreliable,
inaccurate advice, your vet may be sceptical if you quote this website.
I understand that. In these cases it may help if you provide your vet with some evidence of
the US philosophy and experiences regarding sub-Qs. Unfortunately there
are no studies into using sub-Qs per se. This is because it is
such a routine treatment in the USA that it would be considered
unethical to withhold fluids from a control group in a study.
Try printing out some of these web pages. The first two are actually by
British veterinary specialists. Surely if they consider sub-Qs to be
appropriate in some cases, why not your vet?
In
Chronic renal failure in the cat
(2006) Sparkes AH Presentation to the World Small Animal Veterinary
Association World Congress, Dr Sparkes, of the UK Animal Health
Trust, mentions giving sub-Qs at home.
The International Renal Interest Society
recommends that vets should "give fluids parenterally as necessary to
maintain hydration" to cats in Stages 3 and 4 of CKD, i.e. when
creatinine is over 2.9 US or 250 international. Parenterally means via
injection rather than orally.
Dr Katherine James
is a US vet who specialises in feline renal medicine, in which
she obtained her PhD. She now acts as a consultant to the Veterinary
Information Network. Her website mentions sub-Qs under Some
Keys to Successful Management.
Long Beach Animal Hospital explains
how they routinely teach their clients how to give sub-Qs at home
(click on Home Administration).
Vetinfo
for cats
- Dr Mike Richards discusses how the majority of his CKD client cats
survive 1-3 years after at home sub-Qs are begun, with the record
being 8 years - click on Kidney Failure: Daily Fluid Treatment.
In
Management of chronic renal failure: beyond the
can (2001), Presentation to the Atlantic Coast
Veterinary Conference, Melissa Wallace states that if a patient "is having
trouble maintaining hydration due to polyuria, then subcutaneous
fluids on an ongoing schedule are very helpful, especially in cats."
Sub-Q Testimonials provides testimonials from a number of people on how
successful a treatment sub-Qs have been for their cats; print this out and show it to your vet if necessary, in order
to emphasise what a mainstream treatment this is in the USA and
Canada.
If you are
in the UK and cannot win your vet's support, you may need to think about
changing vets. It is not ideal timing having to do this when your cat is
sick, it is not easy finding a UK vet who permits sub-Qs, and many vets are reluctant to take on clients of another vet.
If you are lucky enough to find a vet who will work with you, do not make negative comments about your first vet but
focus on moving forward and establishing a relationship with the new
vet.
If you are looking for a new vet, unfortunately the list of vets I keep
is very short, so the chances of such a vet being in your area are sadly
rather low. I therefore recommend that you join
Tanya's CRF Support Group
and ask if anyone can recommend a vet in your area. I do
read all messages sent to the group and I or one of the group moderators will contact you privately if
there is a vet on the list in your area.
If you live in a remote area with limited choice of vets, or if you are
unable to travel easily, ask your vet about using
oral
fluids instead. These may not be sufficient for cats with moderate
CKD but they could help.
Fluids are not
always appropriate, and should only ever be administered with
veterinary approval. Subcutaneous fluids should NOT be
administered to
your cat if any of the following criteria apply:
your cat is so severely dehydrated that your vet
considers IV to be more appropriate. In certain circumstances IV is
the only correct treatment. My vet only agreed to me doing
subcutaneous fluids at home on the strict understanding that they were
not to be viewed as a substitute for IV treatment in times of crisis;
your cat has a heart condition (fluid therapy may
still be possible but your vet must decide if it is appropriate for
your cat, and determine the amounts and frequencies to be
administered);
your vet has refused to agree to the procedure on
other medical grounds;
the fluids from the previous session have not yet
been absorbed: this may be obvious, or your cat may feel "squishy".
Squishiness sometimes happens if a little air gets in with the fluids,
but if it happens consistently, your cat may be over-hydrated and need
less fluid; see
Treatments for more information.
If your cat is prone to such problems, you may wish to monitor your
cat's weight with
baby
scales;
processing the extra fluids in itself places an
additional workload on the kidneys which can make the CKD progress
faster; plus it can flush out certain nutrients, and giving fluids when
they are not needed may increase blood pressure; so it is best not to
begin fluids until the advantages are likely to outweigh the
disadvantages. Dr Katherine James of the Veterinary Information Network
believes that most CKD cats will benefit from subcutaneous therapy once creatinine
levels are consistently over 300 -350 (US: 3.5-4). If your vet thinks your cat's
CKD is less advanced than this, then it is probably safer to hold off on
sub-Qs for the moment;
my vet agreed
to us doing fluids in part because she felt Thomas would not find them
too distressing. You and your vet do need to take your cat's personality
into account in deciding whether to go this route; but do not
necessarily assume your cat cannot cope, many cats who ordinarily hate
medication of any kind tolerate sub-Qs because they make them feel so
much better. I would suggest trying them for a few weeks at least.
When my Thomas first crashed in
December 1999, he had a urea level of 46 (BUN of 241). He spent four
days on IV fluids and came home on Christmas Eve. My vet had reluctantly
agreed to sub-Qs at home, and I was supposed to start on Boxing Day, but
I got real, proper flu and was in bed for nearly a week, so I was unable
to give them. As a result, Thomas crashed again in early January. I
asked my vet to put him back on IV fluids and she looked me in the eye
and said "how many times are you going to ask me to do that?" I said as
many times as necessary, but obviously it could hardly be a weekly
thing. I hoped sub-Qs would be the solution. Thomas was stabilised on IV
fluids once again, then he began his daily sub-Qs. He never needed IV
fluids again, and never crashed until his final days seven months later.
You can read Thomas's full story
here.
By March 2000 Thomas was doing great. My vet could clearly see how
effective the fluids had been and she told me that, back in December 1999 when Thomas first
crashed, the entire practice had thought "you were, er, m..." and I said "mad?" and she laughed and said
"no, misguided". Apparently every single member of staff
thought that us giving sub-Qs would be a waste of time and
effort, and she only agreed to us trying because she felt it couldn't harm
Thomas and it might make him more comfortable. And I think she felt sorry
for me, and did it as much for my sake as for Thomas's - she knew I'd
feel better if I knew I'd tried all I could.
Thank God I have an open-minded vet! It probably helped that my vet knew
me. Earlier in 1999 I had adopted a cat she had rescued and she knew I
moved heaven and earth to help my cats. But even if you have to move to
a new practice, take heart. You want to find a vet who will partner you
in caring for your cat, not patronise you. They do exist, I promise. You
just have to find one of them.
Great news!
I maintain a list of British vets who permit sub-Qs, so please send me
your vet's contact details so I can add them to the list. The list is private
because some of the vets do not want their details on the internet, so
I do not publish it on the site.
Sometimes your vet will permit you to try sub-Qs, but, being
unfamiliar with the concept, may not offer you the most appropriate
equipment or technique. If problems then arise, you might be told "I
told you so" rather than be given help obtaining better equipment or
improving your technique. So if your vet does agree to you trying Sub-Qs,
check out all the pages in the
Fluid Therapy section,
especially the
Tips on
Giving Subcutaneous
Fluids page, to learn more
about doing this in the easiest way for both you and your cat.
My vet now makes sub-Qs available to other patients when appropriate.
One interesting observation: nobody has yet taken her up on her offer!
This made me realise that sometimes the issue is not only the vet's
approach but also that of the typical British client, who is happy to
give the odd pill but that is about it.
You are not the typical client. You are going to fight to use sub-Qs.
This could help you save your cat's life, but whatever happens, it will
certainly make however long your cat has left a lot more comfortable.
You will also contribute to an eventual change of approach that will
make a massive difference to many other cats' lives.
TREATING YOUR CAT WITHOUT VETERINARY ADVICE CAN BE
EXTREMELY DANGEROUS.
I have
tried very hard to ensure that the information provided in this website is
accurate, but I am NOT a vet, just an ordinary person who has lived
through CKD with three cats. This website is for educational purposes
only, and is not intended to be used to diagnose or treat any cat. Before
trying any of the treatments described herein, you MUST consult a
qualified veterinarian and obtain professional advice on the correct
regimen for your cat and his or her particular requirements; and you
should only use any treatments described here with the full knowledge and
approval of your vet. No responsibility can be accepted.
If your cat
appears to be in pain or distress, do not waste time on the internet,
contact your vet immediately.
This site was
created using Microsoft software, and therefore it is best viewed in
Internet Explorer. I know it doesn't always display too well in other
browsers, but I'm not an IT expert so I'm afraid I don't know how to
change that. I would love it to display perfectly everywhere, but my focus
is on making the information available. When I get time, I'll try to
improve how it displays in other browsers.
You may print
out one copy of each section of this site for your own information and/or
one copy to give to your vet, but this site may not otherwise be
reproduced or reprinted, on the internet or elsewhere, without the
permission of the site owner, who can be contacted via the
Contact Me
page.
This site is a labour of love, from which I do not make
a penny. Please do not steal from me by taking credit for my work.
If you wish to
link to this site, please feel free to do so. Please make it clear that
this is a link and not your own work. I would appreciate being informed of
your link.
5.
If your vet says sub-Qs are painful, ask on what
this opinion is based. My vet agreed to me giving fluids because she believed that the sensation of the fluid going under
the skin might feel a little strange, but she did not think
they were painful. Unfortunately many UK vets do genuinely believe
that sub-Qs are painful and stressful if given regularly, not least
because few UK vets have any
experience of sub-Qs being used on a regular basis. Look at Cookie
(left) - does he look like he is in pain? Does he look traumatised? My Thomas did not fight fluids at all, he did not
cry, he just sat quietly, and it was all over in under five minutes a
session, as the photos in
