The very idea
of giving subcutaneous fluids to your cat be pretty scary at first, but
there are ways to make it easier for both you and your cat.
The type of
fluid you use can make a lot of difference to your cat's comfort levels.
This page explains more about the different types of fluids that are
available.
It also
discusses the best type of needles (Terumo), how to prepare and calm
your cat (including the famous clothes pin trick) and what to expect
both during and after the procedure.
Key Tips
Giving sub-Qs for the first time is scary! It may never be something you
look forward to, but there are ways to make the process go more smoothly
which not all vets are aware of, so they may not tell you about them. If
you follow these tips, you and your cat still may not necessarily enjoy
the process (although some cats realise that sub-Qs make them feel better
and actually remind their human if they are late giving them!), but it
should make it tolerable for you both.
Remember, you're doing this to help your cat. Sub-Qs do help!
The key tips:
Warm the fluids. Cold fluids can be very uncomfortable.
Use Terumo UTW (ultra thin walled needles) if possible. These can make an incredible
difference to your cat's comfort level yet few vets use them.
You don't have to only use the scruff of the neck. You can use the area
that would be covered by a saddle.
Try to get into a routine. Most cats like routine. Even if your cat never
grows to like sub-Qs, if s/he knows you always do them at 6 p.m., s/he
will remain relaxed around you the rest of the time (yes, of course cats
can tell the time!).
Is your cat the demon cat from hell? Try the clothes pin (peg) trick!
It can often make even the wildest cat co-operate.
What You
Will Need
You will need
several items in order to give your cat sub-Qs. Vets can normally supply
these items, and it is worth obtaining them from your vet the first time
or two and being shown how to give sub-Qs by your vet or vet tech.
Most
people do eventually start sourcing their own supplies in order to save
money.
See the
Obtaining Supplies Cheaply section for information on where to buy
fluids, needles and administration sets:
Essential Supplies When
Using the Giving Set Method
This is the
most common way of giving fluids in the USA.
Fluid bags
Most people
use a type of fluid called lactated ringers solution (LRS) but sometimes
other types of fluid are appropriate. See below for more on this.
Needles
You have to
insert the needle into your cat to allow the fluids to flow into him or
her. Ideally you want Terumo ultra thin wall needles.
Fluid
administration set (giving set or venoset)
This enables
you to attach the bag of fluid to the needle. The fluid flows from the
bag through the administration set and into the needle and then into
your cat.
Optional
Supplies When Using the Giving Set Method
IV pole
Some people
find these helpful to speed up the process.
Weighing
scales
These can be helpful for measuring the amount of fluid you are giving.
Burette or
buretrol
These items
are used by some people to measure accurately how much fluid they are
giving.
Calming or
restraint method
Some cats do
better when these are used. See below for options.
Baby food
or other treats
Some people
use these to distract their cats during fluids, others use them as a
reward afterwards.
Essential Supplies When
Using the Syringe Method
This is the
most common way of giving fluids in the UK and is also used by some people
in the USA.
Fluid bags
Most people
use a type of fluid called lactated ringers solution (LRS) but sometimes
other types of fluid are appropriate. See below for more on this.
Syringes
You use these
to measure out the fluid which you are going to inject into your cat.
Needles
You use these
to draw the fluid out of the fluid bag into the syringe, ready to give
to your cat.
Winged
infusion sets
These are
used to inject the fluid into your cat.
Optional
Supplies When Using the Syringe Method
Calming or
restraint method
Some cats do
better when these are used. See below for options.
Baby food
or other treats
Some people
use these to distract their cats during fluids, others use them as a
reward afterwards.
Choosing a Fluid
There are
several different classes of fluid:
isotonic - have the same sodium concentration as body
tissues.
hypotonic - have a lower salt concentration than that in body
tissues.
hypertonic - have a higher salt concentration than that in body
tissues.
All the fluids discussed below (apart from dextrose, which is not
recommended) are isotonic. However,
ISFM consensus guidelines on the diagnosis and
management of feline chronic kidney disease
(2016)
Sparkes AH, Caney S, Chalhoub S, Elliott J, Finch N, Gajanayake I,
Langston C, Lefebvre H, White J & Quimby J Journal of Feline Medicine &
Surgery18 pp219-239 state "although a balanced
electrolyte solution such as lactated Ringer's solution is often used, a
hypotonic solution (half-strength lactated Ringer's or 0.45% saline, with
added potassium as needed) may be preferable to reduce the sodium load."
There are a variety of fluid types available.
The fluid most commonly used for
CKD cats is
Lactated Ringers Solution (LRS), but occasionally other fluid types are
prescribed, usually because of other issues which need addressing. If your vet gives you another type of fluid, do
check this is necessary because some other types can sting, plus some of
them are more expensive than LRS.
Please also always check the bag of fluid before you start to use it in
case you have been given the wrong type:
mistakes can happen.
Introduction to fluid therapy (2008) Dr S
DiBartola
has information about different fluid types and explains why LRS is
the best choice for sub-Qs for cats
.
The DEHP Issue
The plastic of some fluid bags contain a chemical called
diethylhexyl phthalate (DEHP),
which softens the bags. Some people prefer not to use bags containing DEHP
because they are concerned that some of the DEHP may leach into the fluids
themselves, especially if the bag is warmed before use.
The Australian Government Department of Health
mentions that studies into the effect of DEHP on mice and rats found that they
developed liver tumours, but this was after they were fed DEHP in high doses. I am not aware of any studies into the effect of
DEHP on cats.
The US Food & Drug Administration
has concluded that "there is little or no risk posed by patient
exposure to the amount of DEHP released from PVC IV bags during the infusion
of crystalloid fluids (e.g., normal saline, D5W, Ringer's Lactate)".
I would probably avoid DEHP bags myself if I could find an alternative. I
understand that some brands offer DEHP-free bags which usually cost more, but
these days I think just finding fluid bags is an achievement and finding
DEHP-free ones is a bonus. Personally,
if I couldn't find or afford DEHP-free bags, it is not something I would lose
any sleep over because in my opinion, it is more important that a cat who needs fluids
receives them.
Lactated
Ringers Solution (LRS)
Human patients with kidney disease are given fluids containing a buffer
such as lactate, and this is also the most common choice for CKD cats.
The lactate is
important for CKD cats because lactate is metabolised by the liver where
it is converted to bicarbonate, and this aids in the correction of mild
acidosis.
In the USA fluids with lactate as a buffer are known as Lactated Ringers
Solution (LRS).
Ringer's Lactate (2020) Singh S, Kerndt
CC & Davis D StatPearls explains more about LRS.
There are a number of different brands available with
different national drug codes (see
Local Sources for Fluids for
the relevant codes).
The nearest British equivalent is called
Aqupharm No. 11 Hartmann's solution,
although you may also be offered Vetivex 11. These fluids may vary
slightly, and there may also be small differences between human and
veterinary formulations, but they are all broadly the same:
Fluid
Sodium
Potassium
Chloride
Calcium*
pH
Calories per litre
Lactate
LRS mEq/l
130
4
109
3
6.5
9
28
Aqupharm 11 mmol/l
131
5
111
2
6.5
9
29
Vetivex 11 mmol/l
131
5
111
2
6.5
9
29
MEq/l and mmol/L values are the same for the above ions
apart from for calcium ions, where the mmol/L measurement is half that of
the mEq/l measurement, so the Aqupharm and Vetivex fluids each have an
mEq/l value of 4
Introduction to fluid therapy (2008) Dr S
DiBartola discusses (penultimate question) why LRS is the best choice for most cats on sub-Qs.
He states ""I am unaware of clinical situations in
which small animal patients have been harmed by lactated Ringer’s
solution."
Normosol-R/Plasma-Lyte A/Isolyte-S
This is a type of fluid which is sometimes used instead of Lactated Ringers
when a cat has high calcium levels, liver problems or
lymphoma
(a form of cancer).
Normosol-R is the most commonly prescribed fluid in this category, but you may also be offered
PlasmaLyte A, or occasionally Isolyte-S. They are all basically the same
type of fluid, but different manufacturers use different trade names.
There is also a Normosol-M, but this is not usually suitable since it
contains dextrose (see below).
There are two versions of Normosol-R, one with a pH of 6.6 (similar to LRS,
which has a pH of 6.5) and one with a pH of 7.4. Plasma-Lyte A also has a pH of
7.4. For cats with high calcium levels, the more alkaline varieties (pH of
7.4) may be a better choice.
Fluid
Sodium
Potassium
Chloride
Magnesium
pH
Calories per litre
Buffer
Normosol- R
140
5
98
3
6.6
18
Acetate 27 Gluconate 23
Normosol- R
140
5
98
3
7.4
18
Acetate 27 Gluconate 23
Plasma-Lyte A
131
5
98
3
7.4
18
Acetate 27 Gluconate 23
Isolyte S
141
5
98
3
7.4
18
Acetate 27 Gluconate 23
These products contain magnesium, so may not be suitable if your cat has
high
magnesium levels.
This type of fluid also seems to sting some cats or make them twitch when
the fluids are administered (see
Symptoms for other possible causes of more frequent twitching), so
cats may resist being given this type of fluid. A lot of vets don't seem to be
aware of this possibility but
Managing fluid and electrolyte disorders in renal
failure (2008) Langston CE Veterinary Clinics Small Animal
Practice38 pp677-697 states (page 11) "Plasmalyte is reported to
sting when administered SC."
Introduction to fluid therapy (2008) Dr S DiBartola states "The low pH and high acetate content
of some Plasmalyte products and Normosol R may contribute to pain on
subcutaneous injection."
There have also been quite a few
reports of cats vomiting after being given this type of fluid. All of these
products are also more expensive than Lactated Ringers and may be harder to
find. I therefore recommend
that, if at all possible, you should use
lactated ringers instead.
Saline
Solution (Sodium Chloride or NaCl) 0.9%
Saline solution
(sometimes referred to in human medicine as "normal saline") may be
suggested by some vets, but it tends not to be the best choice for a CKD cat
because:
it does not have added potassium, which many
CKD cats need.
the higher sodium load is additional work
for already damaged kidneys to process
it is not usually suitable for cats with hypertension or liver problems.
it can sting when injected
subcutaneously which may make the cat resist sub-Qs
However, it is sometimes appropriate for:
cats with high calcium levels (though Normosol-R may be a better choice); or
cats with
hyperkalaemia
(high levels of potassium), who may initially be placed on intravenous sodium
chloride in hospital
Fluid
Sodium
Chloride
pH
Buffer
Sodium Chloride 0.9%
154
154
4.5 - 7.0
None
One possible compromise would be to use half strength (0.45%) sodium
chloride fluids.
ISFM consensus guidelines on the diagnosis and
management of feline chronic kidney disease (2016)
Sparkes AH, Caney S, Chalhoub S, Elliott J, Finch N, Gajanayake I,
Langston C, Lefebvre H, White J & Quimby J Journal of Feline Medicine &
Surgery18 pp219-239 state "although a balanced
electrolyte solution such as lactated Ringer's solution is often used, a
hypotonic solution (half-strength lactated Ringer's or 0.45% saline, with
added potassium as needed) may be preferable to reduce the sodium load."
Dextrose
These fluids
contain dextrose, a form of sugar. Therefore they do contain a few
calories, though not enough to be of any real benefit (8.5 calories per
100ml of fluid). These fluids are sometimes used when appropriate as
intravenous fluids in a hospital setting but they are not usually
appropriate for home use because:
the sugar means
that bacteria can easily grow in the fluid and cause infection at the
injection site.
fluids
containing dextrose may sting when administered via sub-Qs.
fluids
containing dextrose also have a shorter lifespan than non-dextrose fluids.
Occasionally
vets may dispense this sort of fluid in the form of 2.5% dextrose added to
either 0.45% sodium chloride or to LRS, as a way to reduce the amount of
sodium your cat is receiving. I don't really see much benefit from adding
dextrose, which has few advantages for CKD cats.
Pet Place discusses the need to avoid giving
sub-Qs with added dextrose.
Introduction to fluid therapy
(2008)
DiBartola S discusses why fluids containing dextrose are best avoided for sub-Qs for cats.
Managing fluid and electrolyte disorders in renal
failure (2008) Langston CE Veterinary Clinics Small Animal
Practice38 pp677-697 states (page 11) "Dextrose-containing
fluids increase the risk of abscess formation... when administered SC."
Preparation
Preparation is the key with sub-Qs. You want to have the best equipment
possible, and you want to have a system in place to increase your chances
of success. It is fine to buy a few supplies from your vet to tide you
over until you've read through this page and the
Obtaining
Supplies Cheaply page and sorted out your plans for which supplies to
use and where to obtain them.
The first thing to do is to practise giving sub-Qs — on an orange. The
feel of a needle going into an orange is similar to that of a needle going
into a cat, so give it a go and see how it feels. Just use the needle,
don't bother with the fluids. You just want to feel the sensation. You can
also practice on a piece of raw chicken with skin. Try to inject the
needle between the skin and the muscle.
If you give your first sub-Q to your cat at the vet's, you may well find
your cat behaves better there, but don't be surprised if your cat is less
co-operative at home, where s/he does not expect this sort of treatment
and is probably less fearful and therefore less afraid of letting you know
what s/he thinks! You may also find that your first few sessions at home
go well, but then your cat starts to object. This is also normal.
Most people do find that their cat eventually accepts sub-Qs at home. If
you don't succeed, don't beat yourself up
but instead look into alternatives, such as having a vet nurse/tech come
to your home to help you, or taking your cat to the vet for
treatment.
Fluid bags have an expiration date on them. Do not use them beyond this
date.
Once you have opened a bag
of fluids, you should ideally not use it for longer than ten days. If you are giving 100ml
of fluid every day, this is not a problem, but if you are only giving fluids
every other day or small amounts at one time, this means you will probably have to
discard a 1 litre bag before you have finished it. It is possible to buy 500ml
bags of fluid, but these tend to work out more expensive than buying 1 litre
bags and discarding what you don't use. See
Obtaining Supplies
Cheaply for fluid purchasing options.
Some people do use opened bags for longer than ten days without problems. In
fact,
Assessment of sterility of fluid bags maintained for
chronic use (2011) Matthews KA & Taylor DK Journal of the
American Association for Laboratory Animal Science 50(5)
pp708–712 did find that "fluid bags used chronically can be maintained in
a sterile condition for a maximum of 30 days" but that study was using
syringes to remove the fluid from the bags (see
How to Give
Subcutaneous
Fluids: Syringe Method) rather than
using giving sets. Personally, I would err on the side of caution because
CKD cats are immune-compromised, but if you do decide (with your vet's
approval) to keep an opened fluid bag for longer than ten days, I would
not keep it beyond thirty days.
Fluids may be kept in the fridge and removed shortly before use, but if you
are going to use up the bag within ten days of opening it, it is
usually not necessary to do this; fluid bags are not usually refrigerated in
hospitals.
The US National Library of Medicine
mentions that fluids should be stored at room temperature of 25° C (about
65° F). We stopped refrigerating our fluids
and had no problems.
Regardless of how long each opened bag lasts, always check the bag before each
use. In order to avoid any possible problems with infection or contamination, never
use a bag of fluids if the contents look cloudy. Often the bag itself will
look a bit misty with condensation, particularly if you have just removed it from the fridge,
but if the contents themselves look cloudy, that is a red flag.
I am sometimes contacted by people whose fluids have been left outside by
delivery people in extreme temperatures, and they are concerned about the
viability of the fluids.
If the fluids are left outside in warm weather,
they may still be safe to use, depending upon how long they were outside
and how hot it was.
Hospira says "Store at 20 to 25°C (68 to 77°F)." It also says
"Exposure to temperatures above 25°C/77°F during transport and
storage will lead to minor losses in
moisture content. Higher temperatures lead to greater losses. It is
unlikely that these minor losses will lead to clinically significant
changes within the expiration period.”
Freezing temperatures are more of a concern. Hospira says "Protect from
freezing." If you live in a cold location, try to order fluids locally,
but if they are being shipped, try to order them early in the week so they
are delivered to you before the weekend.
You can often make a claim for fluids that are not delivered properly, and
that is probably the wisest move if it is an option.
Fluid Warming
When used
straight from the fridge or even at room temperature, many cats find the
fluids uncomfortable and may twitch (room temperature is after all a lot
lower than a cat's body temperature). Therefore you should warm the fluids before
use. Place the bag of fluids and the giving set (keep the port openings
out) in a bowl full of hot water, ensuring that
the entrance to the bag (where the marker is) is not immersed, and leave
to warm for ten minutes. Some people have found that filling a cooler box with hot water
or using a styrofoam container to insulate the bowl works well. Alternatively, you could use
a heatpad to warm the fluids.
When you connect the fluid bag to the fluid administration set, run a
little fluid through the line before you give it to your cat to ensure
your cat does not receive cold fluid remaining in the administration set.
Make sure the fluids are not so hot that they will burn your cat! You can
buy an infrared digital thermometer to check the temperature - I bought
one from Radio Shack which cost about US$10.
Warming fluids in the microwave is not recommended because it is hard to
get the right temperature so you may find the fluids are too hot in
places.
A small number of cats do prefer the fluids at room temperature so
experiment to see what works best for you both.
If you take your cat to the vet for fluids, you may find they do not warm
them. Discuss with them whether it would be possible to do so if you think
it would make your cat more comfortable.
All About Needles
In order to give your cat sub-Q fluids, you will need hypodermic needles.
All needles are universal, i.e. they will fit any administration set.
Needles are widely available from a number of different manufacturers and
are single use only
(see below to understand
why). If you don't get the needle in correctly the first time, throw it
away and use a new one.
A needle is sterile and should be kept that way until use, so
after you've given your cat fluids, remove the needle from the end of the line
and place a new needle complete with cover on, ready for your next session. Only
remove the protective covering or cap from the needle when you are about to use it.
Hands up, those with a needle phobia. Join the club! I did master the art
of giving sub-Qs despite my own needle phobia. In twenty years of running this site, I've only heard of one person who
did not master giving sub-Qs herself because of a needle phobia (She never even tried). Please give
it a try. It's much cheaper for you and less stressful for your cat if you
learn to give sub-Qs yourself at home.
Many vets routinely stock Monoject needles or other brands. Some people use these without any problem, and many people
use them initially when they have not yet had time to shop around for
supplies. However, the best needles for CKD cats are widely considered to
be those made by Terumo.
Why are Terumo needles so good?
They are extremely fine but
still very sharp.
Terumo
states that its Sur-Vet veterinary needles have been shown to be the
sharpest on average among brands tested (10% sharper than
BD needles and 16% sharper than Covidien needles). Other
needles are referred to as "kitty harpoons" on Tanya's CKD Support Group, but Terumos slide in like a
sharp knife through soft butter.
The diameter of the inside bore of some Terumo needles (see
below for
information on needle sizes)
is
larger than another manufacturer's needle of equivalent size, allowing
greater flow rate.
Terumo Europe has a photo of how this works. This feature means it takes less time to give your cat sub-Qs.
If you haven't
yet used Terumo needles, give them a try if you can. I regularly hear from people who
cannot believe the difference they make to their cat's comfort levels and
their own stress levels! I even heard from a professor at the University of
California at Davis College of Veterinary Medicine who told me he had been
unaware of Terumo needles until he read about them here, but he was now
using them all the time because he found them so much better.
Some people find it can be hard to take the
covers off Terumo needles. There are various ways to do it, but one way that
seems to work is to attach the needle to the IV tubing, then twist and tug the
cover quickly. Alternatively you can rock the cap to and fro to loosen it,
then pull up quickly. Terumo now makes a new style of needle with a guard
which is easier to open, but most needles with this feature are not UTW.
Terumo used to refer to their extra fine needles as ultra thin wall (UTW).
Terumo veterinary products mentions the
unique bevelling and ultra thin wall needles but there do not actually
appear to be any UTW needles available on the page. Apparently this is due
to an FDA regulation. However, the page does say
"Featuring a unique double bevel and ultra-thin wall design," and the
reference number for the 20g 1 inch needle (NN-2025R) is the same, except
it is now called "thin wall" and previously it was called "ultra thin
wall." Therefore I believe if you use Thin Wall (TW) needles, you
should be OK. Certainly most people find the needles described as Thin
Wall rather than Regular do the trick.
I have asked Terumo for more information but they never respond to me, which is a bit rich when
you think how much custom they must get via this website!
You can obtain details of mail order suppliers for needles in
Obtaining
Supplies Cheaply. You can expect to pay around US$6-10 for 100 needles.
According to
ASD Healthcare, some Terumo needles were
recalled in February 2019 because of possible sterility issues.
Nipro make an
ultra thin walled needle called Flomax. I have heard from a few
people who have tried Nipro needles and while they don't find them as
sharp as Terumo and think they do not flow as fast, overall they are
satisfied with them.
Terumos in UK and Europe
In the UK, Terumo needles used to be branded as
Neolus, and ultra thin wall
needles (sometimes referred to as ultra fine wall or as triple faceting) were available.
They are still mentioned on Terumo Europe's website, so may still exist. I
note they have the same codes as the North American Terumos.
Terumo Europe
says "Their T-SharpTM-bevel design with triple faceting
facilitates the penetration of the skin and minimizes trauma."
Terumo also sells needles branded as Agani, and one
seller,
Medisave
states "formerly called Neolus" but then goes on to describe them as thin
wall rather than ultra thin wall. However, another seller,
MediSupplies,
also states that these needles were formerly known as Neolus but then adds
"unique
double bevel design."
So it is not clear whether they are ultra thin wall or
not; but I think they probably are; plus they do appear to be all that is
now available in the UK.
If you are giving sub-Qs with a syringe, you will normally need winged
infusion sets. These help you when inserting the needle and give you
something to hold when you are switching syringes over.
Terumo Europe sells these under the Surflo name,
but it is not clear whether they are ultra thin wall (they were when I used them).
Choosing Needles: Size and Speed
The size of needle used can make a tremendous difference to your and your
cat's comfort and stress levels.
On the packet it will say something like
21G x 5/8". The first number with the G is the gauge, i.e. the needle
size. The second number
is the length of the needle in inches, so this needle is 5/8 inches long.
The higher the number (gauge) of the needle, the finer—smaller—the needle.
If you choose a needle below size 18, it can be rather big and
uncomfortable for the cat (size 16, for example, is often used on goats
and sheep). On the other hand, a needle above size 23 can mean it takes too long to give the fluids.
Needles also come in different lengths, the most common being 5/8 inch or
1 inch. You are less likely to accidentally poke the shorter needle into
your cat and out the other side, but on the other hand, it is harder to
adjust the smaller needle (for example, if the fluid isn't flowing
properly and you wish to move the needle a little). The length of the
needle is a personal choice, but most people seem to like the 1 inch
length.
If your cat dislikes fluids, you need to decide if it is the actual sticking
that bothers him/her, or if it's the length of time it takes. If it is the
sticking that is an issue, opt for size 20 or above ultra thin wall Terumo
needles.
If it's the length of time it takes to give the fluids, opt for a size 18 or
19 which will get the job done quicker. Most Tanya's CKD Support Group members
use size 19 or 20 because these give a balance between size of needle and
speed of fluid flow. Those using a size 20 or above usually opt for Terumo
ultra thin wall
needles if possible.
Rad, whose lovely cat, Purr Box, is the model in
How to Give Subcutaneous Fluids: Giving Set Method, ran an experiment regarding the
flow rate of various needles. Here are the results of his experiment, which he
has kindly given me permission to publish here. The flow rates (all for 100ml
of fluid) are in minutes
and seconds.
Needle
Details
Speed of
Flow in Minutes and Seconds
Brand and Size
Length (inches)
Type
First Flow Test
Second Flow Test
Average Flow Rate
Terumo 18
1
TW
00:55
00:51
00:53
Monoject 19
1
n/a
01:11
01:09
01:10
Becton Dickinson 18
1
n/a
01:14
01:10
01:12
Terumo 19
1
TW
01:17
01:16
01:16
Monoject 18
1
n/a
01:15
01:18
01:17
Terumo 20
1
UTW
02:02
01:56
01:59
Becton Dickinson 20
1
n/a
02:28
02:29
02:29
Monoject 20
1
n/a
02:32
02:34
02:33
Terumo 21
1
UTW
02:39
02:37
02:38
Terumo 22
1
UTW
04:05
04:13
04:09
Terumo 21 (Sur-Vet Label)
1
TW
05:59
05:53
05:56
Monoject 22
0.75
n/a
06:04
06:12
06:08
Monoject 22
1
n/a
06:21
06:08
06:15
Terumo 23
1
UTW
07:16
07:03
07:09
Monoject 22
1.5
n/a
07:21
07:13
07:17
Terumo 25
1
UTW
13:21
13:20
13:20
TW
Thin Wall
UTW
Ultra Thin Wall
Freezing Needles
Some people
freeze needles before using them. This is because of a study,
Pain associated with injection using frozen versus
room-temperature needles (2001)Denkler K Journal of the American
Medical Association286 p1578, where a plastic surgeon who froze
needles before using them on his (human! - what cat needs plastic
surgery?) patients found that 76.6% of the patients found the frozen
needles less painful.
Freezing the needles doesn't always seem to make a difference for cats,
but it might be worth a try. If you decide to try this, do not freeze the
needles for longer than a few days in case it adversely affects the
sterile packaging.
IV Administration Sets (Venosets or
Giving Sets)
If you are giving sub-Qs by letting the fluid drip out of the bag (giving
set method), you
need a venoset, also known as an IV administration set. You usually need a prescription (it
depends which state you live in).
As with fluid bags, you may wish to use a
DEHP-free set (Hospira
makes one, among others).
There are two factors to consider with administration sets, the flow rate
and the length. In terms of length, these
sets come in a variety of lengths but most people seem to like 72, 80 or
100 inches long sets.
In terms of flow rate, you will see a drop/ml reference, for example 10
drop/ml.
10 drop/ml means that 10 drops provide 1 ml, so if you are giving 100ml,
you would be giving 1000 drops. Thus
you want a 10 drop/ml or at most a 15 drop/ml administration set, because
higher numbers/slower flow rate administration sets would take too long.
One thousand drops sounds like a lot, but it will only take you about 3-4
mins to give your cat fluids with this size, depending upon how much fluid
you are giving and what size needle you are using. Obviously a 15 drop/ml
set takes 50% longer to give the fluids than the 10 drop/ml set, but on
the other hand the slower flow rate may suit some cats and mean they
tolerate fluids better. You will have to experiment to see which works
better for your cat.
PharMerica University
has a chart showing the speed of various drop/ml rates.
Some venosets have a luer lock to lock the needle in place, which most
people find helpful. Some venosets have a port which you can use to add
certain medications. If you do this, make sure you only use medications in
a form suitable for this purpose.
Most people use the administration set for 2-3 bags of fluid, as long as
the end to which the needle is attached is kept sterile. When you want to
remove the needle from the administration set, it can be rather difficult.
Using pliers or a pair of rubber gloves can help.
Mar Vista Vet has a helpful video about
preparing for giving fluids.
Dr Mike Ontiveros has a video which shows how
to prepare a venoset for sub-Q fluids.
IV Pole
Since giving fluids via a fluid administration set relies on gravity to deliver the
fluids, many people try to hang the fluid bag high up so as to speed up
the process. You can use a coathanger, but some people decide to buy an IV
pole. This can be wheeled to
your cat, which can be helpful if your cat copes better with fluids while
sleepy.
Amazon sells a suitable pole for
less than $30 including shipping, though it is currently (July 2020)
unavailable.
Dr C Wladis explains how the height of the fluid bag affects the speed of delivery.
Preparing Your Cat
It often helps both you and your cat if you set up a routine, ideally
including set times, and stick to it. You can choose a special word or
phrase that tells them you are about to give them medication and/or fluids.
Your cat will soon learn what this means, and will then not be stressed
when you approach him or her at other times.
Speak to your cat during the procedure and reassure him/her, but don't
overdo it or s/he may think s/he is right to be frightened. Try not to be
nervous yourself or your cat will sense it; aim to be very matter-of-fact
about it all. Tell him/her what you are doing and why — many people find
this seems to help.
Some cats
tolerate sub-Qs better if they are sleepy.
Some cats feel happier if they are given
fluids in a familiar place, whereas others may be more co-operative if the
fluids are given in a strange place, perhaps a room they are not normally
allowed to enter. Experiment and see what works best.
Here are some methods which people have found makes the process easier.
Feliway is a copy of the pheromones
naturally present on a cat's face. When a cat rubs his face on something,
s/he is marking it with these pheromones, which make the cat feel more
relaxed.
Some people find Feliway can be helpful when giving sub-Qs.
Improving the feline veterinary consultation: the
usefulness of Feliway spray in reducing cats' stress (2016)
Pereira JS, Fragoso S, Beck A, Lavigne S, Varejăo AS & da Graça Pereira G
Journal of Feline Medicine & Surgery18(12) pp959-964 found
that caregivers in the study considered their own cats to be
“easier to handle/more relaxed” when given Feliway compared to a placebo.
You can buy Feliway plug-ins and simply leave them on in the room where
you usually give fluids, or you can use the spray version.
Zylkčne is a natural product
derived from casein, the protein in milk.
Life Extension Magazine has an article
about why bioactive milk peptides can be calming.
Effect of alpha-casozepine (Zylkene) on anxiety in
cats (2007) Beata C,
Beaumont-Graff E, Coll V, Cordel J, Marion M, Massal N, Marlois N & Tauzin
J Journal of Veterinary Behavior: Clinical Applications and Research2(2), pp40–46 found that it seems to be effective, and it does seem
to help some cats to accept sub-Qs.
Zylkčne is often available from vets in Europe. In the USA you can find it
on
Amazon. You can open the capsule and mix
its contents with food. It can take a few weeks to start working, so don't
give up too soon.
Distraction and Bribery
Some
cats can be distracted with a little food during sub-Qs. Cookie on the
left was the sort of cat who needed to be sedated for blood draws, yet as
you can see he had no problems receiving sub-Qs, and could easily be
distracted during the procedure with food, so no restraint was necessary. I think this is a great photo for
showing sceptical vets that many cats can tolerate sub-Qs very well.
Dr Sophia Yin has photos and a video
showing how to use treats to train your cat to accept injections.
Even if you prefer not to feed your cat during the
procedure, many cats feel hungry after fluids
so take the opportunity to offer your cat some food afterwards - we always
fed Thomas as his reward for being a good boy.
Restraint
Some cats do better if they
are restrained during sub-Qs, either by hand or by a cat restraint bag, or
in a carrying basket with a top opening. However,
others are more likely to co-operate if they are not restrained and feel
they have some kind of control. If your cat tends not to like being held
generally, s/he probably won't like to be held during the sub-Q process
either. You know your cat best so decide which
would be better.
The
ThunderShirt is not a restraint device but
rather a coat that provides gentle, constant pressure which is supposed to
reduce anxiety. It is intended for dogs, and
The effect of a pressure wrap (ThunderShirt) on
heart rate and behavior in canines diagnosed with anxiety disorder
(2014) King C, Buffington L, Smith TJ, Grandin T Journal of Veterinary
Behavior9(5) pp215-221 found that it appears to be effective. I don't know
if it would be effective for giving sub-Qs (I'm not sure you'd be able to
access the injection area) but I have heard of people using one
successfully to calm their cats in other situations. Please do
not use without your vet's approval.
Comfort cats in a towel wrap
is a video by
Dr Yin on how to handle a difficult cat simply using a couple of
blankets.
Four Flags in the USA sells the Cat
Sack, for holding your cat while you medicate him/her or administer
sub-Qs. It can help with wriggly cats, and most cats do not seem to mind
it. I put this
on my cat and was surprised to see that she didn't mind it at all.
Amazon also sells the Cat Sack in
various sizes at various prices (be sure to buy the correct size for
your cat).
Amazon also sells the Cozy Comfort Carrier, though I don't
know of anyone who has used this type as yet so do not know for sure if
it is suitable..
The Clothes Peg (Clothes Pin) Trick
If your cat wriggles
or gets stressed during sub-Qs, you can try the clothes peg (clothes pin)
trick: this is a form of acupressure recommended
by an acupuncturist vet back in 2000 to a lady called Lori. Here, Joan's Sassy models this trick. Sassy,
left, was not a particularly placid cat, but this method enabled Joan to
give Sassy fluids successfully and with much less stress for either of them.
As usual, please check with your vet before trying this.
Be sure to "clip the kitty" when he or she is calm, and before you begin the
sub-Qs. It won't work once the cat is upset and squirming to get away.
You take standard wooden
clothes pegs (clothes pins), and clip the scruff of the cat's neck starting at
the back of the skull where the skin is loose.
You
attach three clothes pegs side-by-side to form a "ridge" down the centre of
the back of the neck. Some cats might need to have as many as six clothes pegs
placed there for it to be effective. It looks just like a "kitty mohawk" when
done properly.
This
is what it looks like from the side. The clothes pegs can pinch if you don't
clip enough skin in the teeth, so make sure you have enough skin in them to
create pressure, but not to hurt the cat. Most cats should relax quite a bit
within a few minutes - some even lie on their side.
You can then give the sub-Qs lower down. Once you've finished the sub-Qs, you
can remove the clips, and the cat should be fully alert within a few minutes.
You can buy special clips for this purpose now but they work in
exactly the same way as clothes pegs, and clothes pegs are much cheaper
and easier to obtain quickly.
In 2011 I was concerned to learn that several members of the Association
for Pet Behaviour Counsellors have reservations about the use of this
technique. They believe that whilst the cat may appear calm and
submissive, s/he is actually very stressed. In this sense it would be very
similar to the way rabbits trance when you flip them on their backs which
is extremely stressful for rabbits. I am investigating this further.
Ohio State University College of Veterinary Medicine
reports on the rationale for the above study and their
interpretation of the behaviour of the cats in the trial, whom they
consider were not stressed.
Thanks to Lori for providing this helpful tip back in February 2000 and
giving me permission to share it here, and thanks to Joan and Sassy for
the photos.
Time to Begin
So you've got your supplies and your cat, and
you're all ready to go. It can be worth doing a trial run without your cat to
ensure you have all the supplies that you need at the ready. But eventually it
will be time to stick a needle in your cat. And you're terrified. Don't worry, that is completely
normal. The first time might go well or it might not. Don't worry if it's a
bit of a disaster, if you don't get all (or even any) of the fluid in. Many
people only get 30ml or so in the first time. You are going to get better at
this!
Having said that, do try to think positive. Your cat will sense if you are
fearful, and may react to this, creating a vicious circle. So think positive,
and remember, you will both adapt, especially once you and your cat realise
how much better s/he feels afterwards.
Remember, cats
can be good at giving you a guilt trip. Some cats make a fuss even if the needle is not in!
But if it does turn into a bad session, let it go and try again later or the next day.
The website most people find most helpful when they are getting started is
Sophia gets her subcutaneous fluids.
You can
also visit these pages with photos of giving sub-Qs to see the two different
ways of giving sub-Qs:
You do not need to restrict
your injections to the neck area, in fact it is better to move around the
body in order to minimise the possibility of scar tissue forming.
Roughly
speaking, you can inject your cat anywhere which would be covered by a
saddle (as Sophia models
here; scroll
to near the end of the page). Some people move around a little like on a
clock, moving an inch further around each time they give fluids. Others
will give fluids on the left on one day, on the right the next, moving a
little away from the previous injection site each time.
Experiment a
little because some cats have preferences - Thomas much preferred being
injected on his right side to his left. Be careful to avoid the spine
though.
Numbing or Cleaning the Area
Some people use lidocaine but it is not recommended because it can be toxic to
cats.
Pet Place states "Caution should be
used whenever lidocaine is given to cats since they tend to be especially
sensitive to the drug."
Local anesthetic toxicosis
(2000) Welch LS Toxicology Brief says "Cats are sensitive to the
CNS effects of lidocaine, however, so monitor them for seizures when you give
lidocaine as an antiarrythmic or local anesthetic." In
Topical creams and pets: a dangerous -combination
the ASPCA includes lidocaine on its watch list. In any
event, if you use sharp needles, sub-Qs are really not that painful.
You also don't need to
wipe with alcohol first. It needs time to work, about 30 minutes, and since
most people don't wait that long, it's a bit pointless.
Critical Care DVM
says "It is not necessary to “sterilize” the skin with alcohol prior to
inserting the needle. In reality, wiping a little alcohol on the skin does not
sterilize it, and the odor and feel of alcohol may aggravate your pet."
If you are keen to clean the area, ask your vet about using chlorhexidine
(hibiscrub). You only need to wait 30 seconds for chlorhexidine to take effect
but it should not be removed until you've finished giving the sub-Qs.
The
Tent
You will find it
easier to inject your cat if you form a good tent (pouch) with the skin.
On the left you can see us making a tent on Thomas.
One reader asked me to mention that if your cat wears a collar and you give
fluids nearby, you need to make sure the collar does not become uncomfortably
tight as a result.
Inserting the Needle
Before you
insert the needle, look to see it is smooth and sharp; on rare occasions needles are faulty and have a little barb which makes
inserting it uncomfortable. If your cat normally doesn't flinch when you
insert the needle, but suddenly does so, this might be the cause.
Another reason
why your cat might flinch when you insert the needle is that you hit
a muscle. Just withdraw the needle, reassure your cat, and try again in
another spot (with a new needle).
Flinching only happens very rarely, but if it seems to happen
regularly, you may be using a type of fluid (such as
saline or
Normosol) which stings, in
which case you may wish to speak to your vet about changing to another
type of fluid.
Occasionally I
hear about cats who yelp when the needle goes in but there does not seem
to be any issue with the needle. If this happens to you, do a fake
injection, i.e. hold the needle near your cat's skin and pretend to inject
by simply touching your cat with your fingers. If your cat still yelps,
you know you've got a cat who likes to give you guilt trips (-;
You need to insert the needle the right way up. The needle will look like this
from the side: ______\ or this: l____. Holding the needle
parallel to your cat's back, insert the needle smoothly into the tent you have
formed.
It can be helpful not only to
move the needle towards the tent, but also to raise the skin slightly to
meet the needle. Ensure you have not pushed the needle through the other
end of the tent. You will soon know if you have done this, because the fluid will leak if so.
Keeping the Needle in Place
I used to hold the needle gently in place (which is easier to do with a
winged infusion set).
EZ IV Harness
has been used by some members of Tanya's CKD Support Group. This can be
shipped internationally. It allows the cat to wander a little, which can
be better for cats who do not like restraint. It helps hold the needle in
place, so you don't need to. If you enter the code tanya, you will receive
a 15% discount.
If the needle does slip out, try again with another needle. However, I
would not stick a cat more than twice in one session, so if the needle
slips out more than once, I would give up and try again another time.
Multiple Needle Sticks
Some vets in the UK recommend using multiple needle sticks, e.g. only
giving 20ml in one place, so a cat receiving 100ml would receive five
sticks. This is completely unnecessary.
International Cat Care
states "Generally around 10-20 ml/kg of fluid can be given at a single
SQ injection site (around 60-100 ml for an average sized cat)."
Trouble Inserting the Needle - Thick Skin
Sometimes the
skin may feel tough so it is hard to get the needle in. There are a number of possible reasons for this.
Firstly, perhaps surprisingly, it can indicate dehydration, in which case your cat
definitely needs the fluids. Secondly, it may indicate scar tissue. This
is actually not that common, and usually doesn't happen for a long time
(months to years) but one way to avoid it is to rotate where
you give fluids (see above).
Stabbing Yourself with the Needle
At some point you will almost certainly accidentally stab yourself with a
needle. This is usually nothing to worry about, it happens to virtually
everyone and is not usually cause for concern. However, if you have a
compromised immune system or if the area becomes red or sore, or if you
are worried, seek medical advice; if you're not up to date on your
tetanus shots, you may be advised to have one.
Giving the Fluids
The actual process should only take 2-5 minutes.
If it's taking longer than this, you need to review the rest of this page
to work out why.
If your cat fights the process, don't panic, but try to find the cause.
Certain types of fluid can sting, see
above for more
information. Not warming the fluids can be uncomfortable for some cats.
Occasionally a needle can be barbed.
If your cat is calm initially but then fights you after a minute or two, it
might be because you are giving too much fluid in one spot and it is
becoming uncomfortable: generally speaking, you should not give more than
100ml in one spot. Also make sure you are holding the needle in place, so
it does not move and irritate your cat.
Some people with fidgety cats use a pressure infusor to help the fluids
flow more quickly. A pressure infusor is a special bag into which a bag of
fluid is placed, and a pump is used to squeeze the fluid out of the fluid
bag more quickly.
The Society of Critical Care Medicine
explains more about how these work.
Bay Medical has a good photo showing what
they look like. You will need a prescription from your vet.
In principle you can give 100ml of fluids in under a minute using a
pressure infusor,
though you have to be careful not to make them flow so quickly that it is
uncomfortable for the cat. Because the fluids flow so quickly, you also
have to be very careful not to give too much fluid to your cat.
In theory the pressure infusor bags should only be used once but some
people use them more than once. Be guided by your vet.
Sun Med produces pressure infusors to fit
various fluid bag sizes.
Measuring the Fluid
It is important to try to give fluids accurately. Giving too much in one
go can be risky, especially for cats with heart conditions. There are a
number of ways to measure how much fluid you are giving, as outlined
below.
If you do accidentally give too much fluid once, it will probably be fine,
but check in with your vet and watch for signs of
overhydration.
Never give any more fluid until the previous amount has been properly
absorbed.
If you are using the
syringe method, you can measure the amount you give
very accurately.
Marking the Fluid Bag
In the USA, there are markings on the bag, often the numbers 1 to 9 or 10.
These numbers represent 100ml, and when you hang the bag up, I am told you
usually have the number 1 at the top. So, for example, if your fluid level
is at 7, you have used 700ml of the bag altogether and have 300ml remaining.
However, many people think the markings are not too accurate, especially
when they get near the end of the bag.
Fluid bags often aren't marked in the UK. Some people mark the bag with a
permanent marker (sharpie) but this was not recommended because the ink
can leach through to the fluids, though
The contamination of intravenous fluids by writing
on the infusion bag: fact or fiction
(2014) Langston JD, Monaghan WP & Bush M International Journal
of Advanced Nursing Studies3(1) pp18-19 found that in fact
this did not happen during their study.
Counting the
Drops
If you are using a fluid administration set, these are measured in drops per ml. Most
people use
either 10 drop/ml or 15 drop/ml sets. If
you want to give 100 ml and
you are using a 10 drop/ml set, then 1000 drops would equal 100ml.
If you want to give 100 ml and you are using a 15 drop/ml set, then 1500
drops would equal 100ml.
Obviously counting this many drops would be very tedious, but you could
consider timing how long it takes to give, say, 100 drops using a 10 drop/ml
set, and then multiply this by ten. So if, for example, it takes 30
seconds for 100 drops to drip into the chamber, then it would take five
minutes (30 seconds times ten) to give 1000 drops or 100ml.
Again, this is not a massively accurate way of measuring how much fluid
you are giving.
Weighing the Fluid Bag
Hanging scales can help you work out how much fluid you have given if
you are using a fluid administration set. 100ml of fluid weighs 100g, so
it is not too difficult to do. Hanging scales are usually the best choice.
Pesola is a popular brand of hanging
scale but is quite expensive.
Hanging scales are also available from Amazon
here and
here.
Amazon UK also has scales which are not
hanging scales but
one member of Tanya's CKD Support Group has used these scales
successfully.
Buretrol/Burette
These terms are often used interchangeably. As far as I've been able to
work out, a burette is a chamber which allows you to measure precise
amounts of fluid. A buretrol is a device containing a burette which
essentially does the same thing when you are giving fluids or other
medications.
Baxter has photos of buretrols.
Buretrols can be useful for measuring the amount of fluid you are giving
to your cat, though bear in mind that some of them come with an attached fluid
administration set, which means that the speed of that set controls how
quickly you can give fluids to your cat. Since buretrols are usually used
for intravenous fluids, where a slow flow is normal, some of them are 60
drops/ml, which is too slow for giving fluids to a CKD cat (see
above for more on drop
speeds). Therefore most people use an add-on buretrol, as shown by The ABCs of IVs,
which means the speed is determined as usual by your administration set
drip rate and the size of your needle.
You attach the spike (pointy bit) on the end of your fluid administration
set into the bottom of the cylinder. You then attach the spike on the end
of the buretrol to the end of your fluid bag.
Another advantage of a buretrol is that you can simply warm the amount of
fluid you are giving that day, rather than having to warm a bag multiple
times.
Most cats feel better after receiving fluids,
and are often more active, with a better appetite. If your cat becomes
lethargic after receiving fluids, or loses appetite, this may be a sign of
overhydration
or heart problems. If your cat vomits, it may be because of the type of
fluid you are using (see above). Speak to your vet about this.
You may
sometimes see a bit of fluid leaking out on to your cat's fur after you remove
the needle; this is normal. If you pinch or massage the injection
area for a minute or so, this will
minimise the possibility of fluids leaking.
Seeing Blood
Occasionally you may see a little blood when you
withdraw the needle. This usually means you have simply nicked a small
vein, and is not normally anything to worry about.
The
Fluid Pouch
After a little
while the pouch of fluid which you have injected will move around the
cat's body. It may go down one of the front legs or just hang on the
stomach. This is normal and is nothing to worry about — think of it like a
camel's hump, to keep your cat hydrated. It should be absorbed gradually
over 6-8 hours.
Still, it is
better to avoid injecting in an area where the fluid consistently moves
down to a front leg because this can be uncomfortable for the cat (try to
move back slightly); and you should never give more fluid until the fluid
in the pouch has been absorbed.
Crackling Noise Under the Skin
(Subcutaneous Crepitus)
Occasionally you may hear a
"crackling" noise under your cat's skin after giving sub-Qs
and/or the cat may seem "squishy".
This simply means that a little air has got under the skin (this is known
as subcutaneous crepitus), and should go away on its own in a couple of
days.
It is not
usually anything to worry about unless it happens regularly. If it does, I would
recommend that you discuss it with your vet because it may mean that your
cat is
overhydrated, in which case you need to reduce the amount of fluid
which you are giving; or you may need to refine your technique so as to
allow less air under the skin.
The Nurse Path Blog
has some information about how to reduce the chances of getting air
bubbles in the line.
Re-Using Supplies
Re-using Venosets (IV Sets)
Most people change the venoset every time they change the fluid bag,
though some people use them for two fluid bags. If you use the venoset for
two bags, switch the
line to the new bag as soon as you've finished the first bag, making sure
not to contaminate it.
Re-using Needles
This is not recommended, because using a needle just once blunts and
distorts the needle which means using it again makes it more painful for
the cat.
Children with Diabetes shows photographs
of how a used needle looks - scary! Re-using a needle also increases the
risk of infection, not a good idea with an immune-compromised cat.
You can obtain needles very cheaply (around US$6-10 for 100 online, see
Obtaining
Supplies Cheaply) so it's really best to use each needle only once.
Needle Disposal
Some vets may allow you to return used needles to them for free, which is
what I used to do.
If your vet does not permit this, you need to find another way of
disposing of needles. You can usually buy a sharps disposal unit from your
vet or local pharmacy for a few dollars or pounds, and you can then return
it to them when it is full (which may incur a small additional charge).
Some people place needles in a rigid plastic container (such as a liquid
washing powder container), screw the lid on tightly and label it "needles"
or "sharps" before placing it in the bin, and this is perfectly legal in
some locations.
Most countries have laws about putting used needles in the trash, so you
need to check the legal restrictions for hazardous waste disposal in your
area.
Safe
Needle Disposal has information about safe needle disposal and
allows you to search for disposal locations in the USA.
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
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This site is a labour of love, from which I do not make
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If you wish to
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