102
2 February 2003
CE Article #2 (1.5 contact hours)
Refereed Peer Review
KEY FACTS
■ Perioperative fluid therapy
is an important component of
hemodynamic stabilization to
minimize drug-exacerbated
hypotension and risks related
to anesthesia.
■ Preoperative resuscitation of the
intravascular fluid compartment
is of prime importance to
improve preload, stroke volume,
and cardiac output, all of which
are suppressed by most
anesthetics.
■ Use of synthetic and natural
colloids for resuscitation
reduces the required volume of
crystalloids and helps retention
of administered fluids in the
intravascular space.
■ Repeated evaluation of physical
examination and laboratory
parameters is important to
ensure adequate fluid
replacement and perfusion,
prevent overhydration or
hypervolemia, and ensure
use of the appropriate fluid.
V Vol. 25, No.
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Guidelines for Perioperative
Fluid Therapy
Colorado State University
Simon T. Kudnig, BVSc, MVS, MACVSc
Khursheed Mama, DVM, DACVA
ABSTRACT: The fluid therapy plan should be tailored to the requirements of each surgical
patient and pertains to preoperative, intraoperative, and postoperative periods. Fluid therapy
plans for compromised and healthy patients differ widely. Fluid therapy plans also differ
according to the type of surgical procedure. This article provides guidelines for perioperative
fluid therapy, outlines the methods of fluid administration, and discusses the monitoring tech-
niques used during blood volume replacement in the surgical patient. Specific suggestions for
various populations and disorders are also presented in tabular form.
T
he following questions must be considered before implementing a peri-
operative fluid therapy plan: Is fluid administration necessary? What type
of fluid is appropriate? How fast and by what route should fluid be
administered? Are fluid additives necessary? A number of factors influence these
questions, including the status of the patient’s fluid, electrolyte, and acid–base
balances; the stage of the perioperative period; the pathophysiologic changes
associated with disease; and whether oxygen delivery to peripheral tissues is
compromised (if so, is it a result of a deficiency in blood oxygen content or
cardiac output?). Perioperative assessment of these factors and the physiologic
changes associated with anesthetic agents enables a clinician to formulate a specific
perioperative fluid therapy plan. Changes in the fluid therapy requirements of a
patient can occur rapidly, emphasizing the need for appropriate monitoring
techniques to enable prompt and precise adjustments to the fluid therapy plan.
PREOPERATIVE FLUID THERAPY
The cardiovascular status of surgical patients should be stabilized as much as
possible before anesthesia. Fluid therapy is an important component of this
hemodynamic stabilization to minimize drug-exacerbated hypotension and risks
related to anesthesia. Preoperative evaluation of a patient includes an assessment
for deficits of the intravascular fluid compartment that manifest in hypoperfu-
sion and of the interstitial and intracellular fluid compartments that result in
dehydration (see Monitoring Fluid Therapy, p. 109). Electrolyte and acid–base
imbalances can further compromise the cardiovascular status of an anesthetized
patient and should be corrected before surgery.1–3 In an emergency, mild meta-
bolic, electrolyte, and acid–base disorders may be corrected in the intraoperative
and postoperative periods. However, extreme hyperkalemia (potassium concen-
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Compendium February 2003
tration >8 mmol/L), acidemia (pH ≤7.20), or hypo-
glycemia (blood glucose value ≤60 mg/L) should be
corrected preoperatively. 4 Management of acid–base
and electrolyte disorders has been reviewed elsewhere.5–9
Guidelines for treating common electrolyte disorders
are given in the box on this page.
Preoperative resuscitation of the intravascular fluid
compartment is of prime importance to improve pre-
load, stroke volume, and cardiac output, all of which
are compromised by most anesthetic drugs.10–11 Isotonic
crystalloid replacement solutions may be used to treat
mild to moderate hypovolemia, with resuscitation fluid
quantities up to one blood volume (50 to 90 ml/kg IV
in dogs, and 40 to 60 ml/kg IV in cats). The intravas-
cular space can be resuscitated by administering incre-
mental fluid boluses of isotonic crystalloids at 10 to 20
ml/kg IV, with reassessment of hemodynamic parame-
ters (heart rate, arterial blood pressure) and physical
parameters between boluses.
Synthetic colloids may be added to resuscitation flu-
Guidelines for Treating Common Perioperative Electrolyte and Glucose Disorders
Hypokalemia
• Do not administer potassium at a rate >0.5 mEq/kg/hr.
• Guidelines for potassium supplementation of fluids
given at a maintenance rate:
Serum Potassium Level mEq Potassium Chloride
(mEq/L) (add to 1 L of crystalloids)
<2.0 80
2.1–2.5 60
2.6–3.0 40
3.1–3.5 30
3.6–5.0 20
• Avoid potassium supplementation of intraoperative
fluids because of the risk of potassium toxicity when
a fluid bolus is given to treat hypotension.
Administration via a CRI is preferred.
Hyperkalemia
• Use physiologic saline or balanced electrolyte solutions
to reduce potassium levels.
• Use sodium bicarbonate (0.5–1.0 mEq/kg IV) to treat
acute hyperkalemia.
or
• Give 50% dextrose (0.5–1.0 g/kg over a few minutes).
• Regular insulin (0.5–1 IU/kg) plus 50% dextrose (2.0
g/U of insulin) can be administered for severe cases.
• Use 10% calcium gluconate (9.3 mg of calcium/ml;
0.5–1.5 ml/kg IV over 10–20 min) for life-
threatening bradyarrhythmias.
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Perioperative Fluid Therapy 103
ids to reduce the required volume of isotonic crystal-
loids and to help retain administered fluids in the
intravascular space. The use of synthetic colloids is
important in moderate to severe hypovolemic shock
because larger intravascular fluid deficits often coincide
with an increase in capillary permeability.12 A rapid IV
infusion of isotonic crystalloids at 40 to 50 ml/kg/hr
(half of one blood volume) and a bolus injection of het-
astarch (Hespan [hetastarch 6% in 0.9% sodium chlo-
ride], B. Braun Medical; Hetastarch [hetastarch 6% in
0.9% sodium chloride injection], Baxter Healthcare
Corp.) or dextran 70 (6% Gentran 70, Baxter Health-
care Corp.; dextran 70, B. Braun Medical; Macrodex,
Medisan) up to 10 to 20 ml/kg IV are recommended
for initial resuscitation of severely hypovolemic dogs.13
In cats with hypovolemic shock, a rapid IV infusion of
isotonic crystalloids at 10 to 30 ml/kg/hr combined
with hetastarch or dextran 70 at 5 ml/kg, administered
over 5 to 10 minutes, has been recommended for initial
fluid resuscitation.13
Hypocalcemia
• Treat acute hypocalcemia with up to 15 mg/kg slow
IV of elemental calcium (10% calcium gluconate,
9.3 mg of calcium/ml) at 0.5–1.5 ml/kg.
• Do not administer the calcium too rapidly because
of possible adverse cardiovascular effects, and
monitor the electrocardiogram during
administration.
• A follow-up CRI at 10 mg/kg/hr can be used if
necessary.
Hypomagnesemia
• Do not add magnesium chloride to calcium-
containing solutions.
• Supplement crystalloids with magnesium (e.g.,
magnesium sulfate) at a rate of 0.75–1.0
mEq/kg/day.
Hypoglycemia
• Treat the underlying cause of hypoglycemia.
• In patients with severe hypoglycemia (glucose level
<60 mg/dl) and neurologic signs, a bolus injection
of 50% dextrose is recommended at 1 ml/kg
followed by a CRI of 2.5% or 5% dextrose.
104 Small Animal/Exotics
Low-volume resuscitation with hetastarch and crys-
talloids has been proposed for patients with cerebral
hemorrhage or edema, pulmonary hemorrhage or
edema, hypovolemic cardiac insufficiency, or chronic
hypoalbuminemia.13–15 While efforts are made to treat
the primary disease, hetastarch is administered at a rate
of 5 ml/kg IV, over 5 to 10 minutes, combined with
maintenance rates of crystalloids (see Postoperative
Fluid Therapy, p. 108). These patients are poorly toler-
ant of interstitial edema, and administration of large
volumes of crystalloids should be avoided. The role of
synthetic colloid therapy in pulmonary edema is con-
troversial, however, because pulmonary edema may
worsen if increased pulmonary endothelial permeability
allows colloid molecules to pass into the interstitium.16
Potential side effects of treatment with synthetic col-
loids include circulatory overload, coagulopathies, ana-
phylactic reactions, and hyperosmotic renal dysfunc-
tion.17 The possible effects of synthetic colloid solutions
on platelet function can be monitored by means of the
buccal mucosal bleeding time; the effect on factor VIII
and von Willebrand’s factor can be evaluated via partial
thromboplastin time. This monitoring is especially
important when multiple synthetic colloid transfusions
are administered.
Hypertonic saline (7% to 7.5%) can be used for the
restoration of intravascular volume in patients with
severe hypovolemic shock or evidence of head
trauma.18–20 An IV bolus of 1 to 4 ml/kg in cats and 4
to 8 ml/kg in dogs is administered over 10 minutes and
should be followed by a crystalloid or synthetic colloid
to augment the volume restoration achieved by the
saline.4,21 The use of a colloid and hypertonic saline in
combination, rather than isotonic crystalloids, has been
advocated to reduce the overall volume of fluid
required for resuscitating patients in shock.20,22,23 If
hypertonic saline is given too rapidly, hypotension
caused by direct vascular relaxation and vasodilation
may occur and can be fatal.24 In patients with cardiac
disease, lower doses of hypertonic saline along with
central venous pressure (CVP) monitoring are recom-
mended to prevent circulatory overload. The use of
hypertonic saline should be avoided in patients with
severe dehydration and hyperosmolar conditions.18
Patients suffering from acute hemorrhage should be
resuscitated with whole blood, packed red blood cells
(RBCs), or an autotransfusion of blood (if a septic or
neoplastic cause is not present) to restore the oxygen-
carrying capacity of the blood. The packed cell volume
(PCV) and hemoglobin content should be increased to
a minimum of 20% and 7 mg/dl, respectively, although
a minimum PCV of 25% to 30% is recommended for
surgical patients.4,25 Any patient receiving blood prod-
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Compendium February 2003
ucts should be observed for immediate transfusion reac-
tions, including anaphylactic shock, pyrexia, urticaria,
restlessness, salivation, vomiting, fecal and urinary
incontinence, and apnea. Oxygen-carrying solutions,
such as Oxyglobin (Biopure Corp.), may have a role in
resuscitation from hemorrhagic shock.26 Oxyglobin has
been shown to be more potent than autologous RBCs
for restoring tissue oxygenation after isovolemic
hemodilution in dogs because of more pronounced
extraction of oxygen from the ultrapurified polymer-
ized bovine hemoglobin molecule. 26 The colloid
osmotic pressure of Oxyglobin, however, is higher than
that of hetastarch, which may cause circulatory over-
load and pulmonary edema if Oxyglobin is adminis-
tered too rapidly.27
Successful treatment of hypovolemia is manifested as
an improvement in cardiovascular and clinical parame-
ters, as discussed later (see Monitoring Fluid Therapy,
p. 109). Subsequent to resuscitation of the intravascular
fluid compartment, a patient’s interstitial fluid deficit
or hydration status is calculated (see Postoperative Fluid
Therapy section, p. 108). A patient should ideally be
completely rehydrated before anesthesia and surgery,
but many diseases necessitate immediate surgical inter-
vention. In these cases, after the intravascular compart-
ment is resuscitated and the patient is hemodynami-
cally stable, anesthesia and surgery may proceed.
Correction of interstitial fluid deficits then becomes a
priority in the postoperative period.
INTRAOPERATIVE FLUID THERAPY
Intraoperative fluid therapy is a continuation of pre-
operative fluid therapy but with the compounding
effects of anesthesia and surgery on hemodynamic sta-
bility. The role of routine fluid therapy for healthy
patients undergoing routine procedures has been ques-
tioned, 28–29 although perioperative fluid therapy for
human surgical outpatients decreases adverse effects,
such as thirst, dizziness, and drowsiness.30 A dosage rate
for intraoperative isotonic crystalloid fluids that is
widely recommended to offset the effects of hypoten-
sion and maintain perfusion during anesthesia is 10 to
15 ml/kg/hr IV. 31 However, lower rates of fluid
administration (3 to 5 ml/kg/hr IV) may be adequate
for many healthy patients after the first hour of anes-
thesia. Prewarming fluids to body temperature before
infusion is recommended for anesthetized patients,
particularly smaller ones that are more prone to intra-
operative hypothermia because of a high surface
area:body weight ratio.
IV boluses of polyionic fluids of 10 to 15 ml/kg are
recommended as a first-line therapy for hypotension in
anesthetized patients with normal PCV and total pro-
Compendium February 2003 105

tein (TP) values, subsequent to an adjustment of anes-

thetic depth. Fluid boluses deliver volume directly to
the fluid compartment requiring expansion, and time
for redistribution to the interstitial and intracellular
fluid compartments is not required. Fluid overload
should be avoided, however, because postoperative fluid
overload has been associated with increased invasive
monitoring requirements and mortality in humans.32
For animals with hypotension that is refractory to iso-
tonic crystalloid therapy, the use of synthetic colloids,
rather than excessive administration of isotonic crystal-
loid fluids, should be considered. In some cases,
expanding the intravascular volume is not enough to
restore adequate blood pressure, and the use of
inotropic agents may be required.33
Blood losses less than 10% of blood volume in a
patient with normal PCV and TP values can be cor-
rected with isotonic crystalloid replacement at a rate of
three times the estimated blood loss amount.34,35 Iso-
tonic crystalloid fluids equilibrate with the extravascu-
lar fluid compartments so that only 20% of the crys-
talloid administered remains in the intravascular space
2 hours after infusion.34,35 An acute blood loss of 10%
of the blood volume in awake dogs with a normal
PCV value produces no significant effect on oxygen
delivery.36 Transfusions of whole blood (empirically, 20
to 25 ml/kg for dogs, 10 ml/kg for cats) or packed
RBCs (empirically, 15 to 20 ml/kg for dogs) have been
recommended in awake patients when more than 25%
of the blood volume has been lost.17,37 While patients
are anesthetized, however, they are less tolerant of
blood loss, and rapid losses in excess of 10% of blood
volume (or a hematocrit value less than 27% to 33%)
indicate the need for whole blood or packed RBC
administration, especially if a patient becomes hemo-
dynamically unstable.38 PCV, however, is not a reliable
indicator of acute blood loss because the PCV of a
patient with an acute loss of whole blood will not ini-
tially change despite a loss in total blood volume and
RBC content.39,40
In surgical procedures that carry a risk of blood loss,
or in patients with a coagulopathy, blood should be
typed and a patient’s blood volume (90 ml/kg for dogs,
60 ml/kg for cats) and maximum tolerated blood loss
(10% to 20% of blood volume) calculated preopera-
tively. Intraoperative blood loss is monitored by count-
ing blood-saturated cotton-tipped applicators or surgi-
cal sponges and by measuring the amount of blood
aspirated from the surgical field. To calculate the blood
loss from blood-soaked gauze sponges and laparotomy
sponges, their weight can be compared with their dry
weight, with 1 g of weight being approximately equal
to 1 ml of blood.41 Alternatively, the following rule of
Table 1. Guide to Perioperative Fluid Therapy in Surgical Patients
Fluid Therapy Considerations Fluid Therapy Recommendations
Pediatric Patients
(e.g., surgery for patent ductus arteriosus or persistent right aortic arch)
Compared with adults, pediatric patients cannot Avoid overhydration of pediatric patients, administer fluids
accommodate volume overload as efficiently and are more at 3–6 ml/kg/hr during surgery, prewarm fluids, and add
susceptible to hypothermia and hypoglycemia. dextrose to fluids for longer procedures.
Pediatric patients also have higher maintenance fluid
requirements because of a high ratio of surface area to body
weight.
Geriatric Patients
Geriatric patients have a decreased cortical renal mass with Avoid overhydration, but maintain renal perfusion.
decreased renal function and reserve as well as a diminished
cardiac reserve.
Geriatric patients are less tolerant than younger patients of
dehydration or fluid overload.
Cardiac Disease
(e.g., mitral or tricuspid regurgitation, dilated cardiomyopathy, hypertrophic cardiomyopathy)
Patients with cardiac disease are susceptible to intravascular Avoid large sodium loads; colloids are an alternative to
fluid overload. crystalloids, but take care not to overexpand the
intravascular compartment as it is more difficult to treat
vascular overload from colloids than crystalloids; 0.9%
saline is the commonly used solvent for colloids.
Use reduced crystalloid fluid administration rates
intraoperatively (3–6 ml/kg/hr); postoperatively, monitor for
volume overload.
Renal Disease
Maintenance of renal perfusion is important to prevent Diuresis (e.g., with mannitol solution) is recommended to
renal ischemia and anuric renal failure. minimize renal damage and shutdown.
Oliguria can be prerenal or renal in origin. Use isotonic polyionic solution plus dopamine infusion in dogs
(2–5 µg/kg/min) to maintain renal output.
Use a slow bolus of mannitol solution over 20–30 min at 0.5
g/kg or CRI at 0.1 g/kg/hr (take care when patient is
dehydrated).
Furosemide may be administered at 1–2 mg/kg IV to promote
diuresis (take care when dehydration and electrolyte changes
exist).
Be careful using low molecular weight synthetic colloids
(especially dextran 40) because they can potentiate renal
disease.
Use an indwelling urinary catheter to monitor urinary output.
In case of oliguria, use a fluid challenge initially with a
crystalloid, and monitor urinary output, CVP, mean arterial
pressure, and heart rate. If urinary output improves (>0.5
ml/kg/hr), prerenal oliguria is likely.
If there is no response to fluid challenge, consider dopamine
(for dogs only; for cats if hypotensive), with diuretic
administration as above.
Monitor for hypervolemia and overhydration.
Uroabdomen
Urine in the peritoneal cavity leads to osmotically induced Stabilize the patient before anesthesia by abdominal lavage
shifts in the fluid compartments. Because urine is and fluid therapy to reduce hyperkalemia.
hyperosmolar, water is drawn from the extracellular See the box on p. 103 for treatment of hyperkalemia.
compartment, which results in hypovolemia. Serum electrolyte
levels equilibrate with those in the peritoneal fluid, which Sodium bicarbonate (0.5–1 mEq/kg IV or 0.25–0.5 × kg ×
results in hyperkalemia, hypovolemia, azotemia, and metabolic base excess [BE] × 0.3 mEq IV over 20–30 min) is used to
acidosis. Hyperkalemia, hypovolemia, and acidosis cause treat significant acidosis and acute hyperkalemia.
impaired cardiac function.
High Gastrointestinal Obstruction
(e.g., pyloric obstruction)
Loss of gastric fluid of low pH can result in hypochloremic, Use of physiologic saline is indicated because of the
hypokalemic metabolic alkalosis. acidifying effect and chloride concentration.
Potassium supplementation is usually required.
Table 1 (continued)
Fluid Therapy Considerations Fluid Therapy Recommendations
Low Gastrointestinal Obstruction
Loss of the duodenal reflux with a high bicarbonate Balanced electrolyte solution is indicated to correct
concentration produces metabolic acidosis. hypovolemia and acidosis and replace electrolyte deficits.
Fluids, electrolytes, and plasma proteins are lost into the Potassium supplementation of IV fluids may be required.
bowel lumen, and increased bowel wall permeability results Severe acidosis (pH <7.2) may require sodium bicarbonate
in increased bacterial migration and absorption of toxins. administration (0.25–0.5 × kg × BE × 0.3 mEq over 20–30 min).
Stagnation of intestinal contents results in bacterial Synthetic colloid therapy or plasma administration should
overgrowth, villus irritation and edema, and malabsorption be considered for hypoproteinemia (TP value <3.5 g/dl) or
of water, electrolytes, and nutrients. hypoalbuminemia (albumin value <2.0 g/dl).
Gastric Dilatation–Volvulus
Impaired venous return, hypoperfusion, hypovolemia, Shock doses of isotonic crystalloids and colloids, hypertonic
endotoxic shock, systemic inflammatory response syndrome, saline, or hypertonic saline plus dextran are given to improve
and mixed acid–base status are common. perfusion before anesthesia. Potassium supplementation may be
indicated.
Plasma plus heparin may be administered if disseminated
intravascular coagulation exists; packed RBCs may be needed
for excessive bleeding.
Sodium bicarbonate may be required for acidemia (see above).
Inotropic support and treatment of dysrhythmias are
important, if indicated, to optimize cardiac output.
Septic Peritonitis
Sepsis and systemic inflammatory response syndrome result Correct fluid and electrolyte imbalances with synthetic
in hypovolemia and increased vascular permeability. Patients colloids and crystalloids; acid–base abnormalities usually
are usually acidemic, hypokalemic, hyponatremic, and return to normal when there is adequate volume expansion.
hypoglycemic. Use potassium supplementation for hypokalemia.
Use heparin and plasma therapy for disseminated
intravascular coagulation.
Add glucose to fluids for hypoglycemia.
Inotropic support and treatment of dysrhythmias are
important, if indicated, to optimize cardiac output.
Liver Disease
(e.g., liver mass, celiotomy for liver biopsy, portosystemic shunts)
With liver failure, avoid fluids containing lactate because Use fluids with acetate or gluconate as bicarbonate precursors.
the liver is responsible for metabolizing lactate. Synthetic colloid therapy may be required for low oncotic
Coagulopathy, hypoproteinemia, hypoalbuminemia, pressure; fresh or fresh-frozen plasma may be needed to replace
hypoglycemia, and sepsis may be present. coagulation factors and albumin.
Use dextrose supplementation for hypoglycemia.
Avoid overhydration with crystalloids in immature patients
with portosystemic shunts.
Pancreatitis
Acute generalized inflammation exists with the release of Correct hypovolemic shock: Improve pancreatic
vasoactive substances and myocardial-depressant factors, microcirculation with isotonic crystalloids and synthetic
absorption of toxins, and accumulation of large amounts of colloids.
fluid within the peripancreatic tissues and peritoneal cavity. Use fresh-frozen plasma transfusions to replace coagulation
Further loss of fluids occurs with vomiting and sequestration factors and α-macroglobulin.
caused by ileus, which results in hypovolemic shock. Take care not to exacerbate pulmonary edema with crystalloids
Intravascular fluid loss similar to extracellular fluid loss; because disruption of alveolar capillary membranes with
electrolyte levels may be normal, but potassium levels may be vasoactive substances is often present.
low because of renal reabsorption of sodium in response to Additional potassium may be required after rehydration.
hypovolemia.
Metabolic acidosis usually exists, resulting from shock.
Brain Surgery or Cerebral Trauma
Avoid cerebral edema. Avoid overzealous isotonic crystalloid administration;
supplement with synthetic colloids; 0.9% saline is the fluid of
choice.
Administer mannitol (1 g/kg IV, take care with dehydration)
and furosemide (1 mg/kg IV, take care if dehydration and
electrolyte changes exist) as needed to treat increased
intracranial pressure.
Avoid glucose-containing fluids unless hypoglycemia exists.
108 Small Animal/Exotics
thumb has been suggested: blood-soaked gauze sponges
(4 × 4 inches) contain 5 to 10 ml of blood, whereas
laparotomy sponges (12 × 12 inches [30 cm2]) mois-
tened with physiologic saline absorb approximately 50
ml of blood.41 The amount of blood lost in aspirated
fluids can be estimated from the following equation:
Amount of = PCV of fluid × Volume of fluid
blood lost PCV of patient
Synthetic colloids or plasma is added to the fluid
therapy regimen in patients with severe hypoproteine-
mia (TP value <3.5 g/dl or albumin value <2.0 g/dl) or
when hypotension is refractory to treatment with crys-
talloid fluid boluses.25 Synthetic colloids can also be
used to replace intraoperative blood loss, when admin-
istration of RBCs is not required and the coagulation
status is normal. The fluid therapy requirements in spe-
cific diseases requiring surgery are given in Table 1.
POSTOPERATIVE FLUID THERAPY
Fluid therapy is continued in the postoperative
period to correct any remaining deficits, provide main-
tenance requirements, and replace ongoing losses. This
therapy is especially important in critically ill patients.
Remaining fluid deficits can be estimated on the basis
of a patient’s physical and laboratory parameters after
surgery. Consideration of a patient’s preoperative
hydration status and the amount of fluid given pre- and
intraoperatively can also guide postoperative fluid
administration rates.
A patient’s interstitial fluid deficit is calculated as
follows:
Milliliters required for replacement =
% Dehydration × Body weight (kg) × 1,000
Percentage of dehydration is a clinical assessment based
on physical parameters and supported by blood assays
(i.e., PCV, TP, blood urea nitrogen, creatinine, pH, lac-
tate) and urinalysis (specific gravity of urine; see Moni-
toring Fluid Therapy, p. 109).
Maintenance fluid requirements can be calculated
from the body weight in kilograms according to the fol-
lowing equations42 and are in the range of 30 to 75
ml/kg/day:
• Dogs: Maintenance fluid requirement per day (ml) =
132 × Body weight (kg)0.75
• Cats: Maintenance fluid requirement per day (ml) =
80 × Body weight (kg)0.75
• Animals heavier than 2 kg: Maintenance fluid require-
ment per day (ml) = 30 × Body weight (kg) + 70
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Compendium February 2003
Abnormal ongoing fluid losses include those from
vomiting, diarrhea, diuresis, transudation into a body
cavity or the tissues, or burn wounds. Third spacing
refers to abnormal accumulation of fluid in extracellu-
lar locations, such as the interstitial fluid space, thoracic
and peritoneal cavities, and around traumatized tissue.
These losses can be difficult to quantify but must be con-
sidered when fluid replacement needs are calculated
because third spacing may lead to hypovolemia, dehydra-
tion, hypoproteinemia, and poor tissue perfusion. The
rate of fluid administration to the postoperative patient
is adjusted according to urinary output, body weight
changes, and physical examination parameters. The cal-
culated daily fluid requirement can be administered over
24 hours unless the patient needs a more rapid fluid rate
to maintain perfusion and urinary output.
When synthetic colloid therapy is indicated, such
as for systemic inflammatory response syndrome or
hypoproteinemia, CRI administered to maintain the
colloid osmotic pressure above 14 mm Hg; the rec-
ommended synthetic colloid dosage is 0.4 to 0.8
ml/kg/hr IV for dogs and 0.2 to 0.4 ml/kg/hr IV for
cats. 43 We administer CRI hetastarch at 1.0 to 2.0
ml/kg/hr IV in dogs and 0.5 to 1.0 ml/kg/hr IV in
cats. High molecular weight colloid molecules
reduce intravascular fluid loss and resulting intersti-
tial edema. Synthetic colloid therapy is contraindi-
cated in patients with severe coagulopathy and
should be used cautiously in patients with renal fail-
ure, congestive heart failure, or pulmonary edema.
When plasma albumin levels fall below 2.0 g/dl or
coagulopathy is suspected, a fresh or fresh-frozen
plasma transfusion is recommended at 10 ml/kg IV
given over 4 to 6 hours.25
METHODS OF FLUID ADMINISTRATION
Perioperative fluids are usually given via an intra-
venous catheter to a peripheral vein, usually cephalic or
saphenous. A central venous catheter is recommended
in critically ill patients to enable measurement of CVP.
The central venous catheter is also recommended for
administering fluids with osmolality values above 500
to 700 mOsm/L to avoid thrombophlebitis. Fluid
administration sets are commonly used, and the num-
ber of drops to be administered per minute is calculated
by the following formula:
Drops per = Desired fluid rate (ml/hr) × drops/ml
minute 60 min/hr
The number of drops per milliliter varies according to
the administration set, with larger sets having 10 to 15
drops/ml and pediatric administration sets having 60
Compendium February 2003
Table 2. Suggested Target Values for Parameters Used to Assess
Perioperative Fluid Therapy
Parameter Target
Colloid osmotic pressure 14–20 mm Hg
CVP 6–8 cm H20 (4–6 mm Hg)
Mean arterial pressure >60 mm Hg, ideally >80 mm Hg
Systolic blood pressure >90 mm Hg
Urinary output >1–2 ml/kg/hr
Heart rate 80–120 bpm in dogs, 160–200 bpm in cats
Plasma albumin >2.0 g/dl
TP >3.5 g/dl
PCV >25% to 30%
Base deficit +4 to −4 mmol/L dogs, +4 to −7 mmol/L cats
Lactate <2 mmol/L
drops/ml. Fluid administration pumps, although an
expensive initial investment, allow a more precise fluid
administration rate when an accurate delivery is critical.
This is especially important in pediatric and small
patients, patients with oliguric renal failure or cardiac dis- administration. Electrolyte monitoring is important
ease, and geriatric patients. Administering perioperative
fluids SC or intraperitoneally is unreliable because
peripheral and splanchnic vasoconstriction limits fluid
absorption. The intraosseous route is an alternative for
puppies, kittens, cats, and small dogs when peripheral
catheterization is difficult.
MONITORING FLUID THERAPY
Monitoring fluid therapy is important to ensure ade-
quate fluid replacement and oxygen delivery, prevent
overhydration or hypervolemia, and ensure administra-
tion of the appropriate fluid. There is no routine means
of measuring oxygen delivery in veterinary patients,
and other subjective and objective parameters must be
used to monitor the effectiveness of fluid therapy. Sug-
gested target values for parameters used to assess peri-
operative fluid therapy are given in Table 2.
Serial body weight measurements and physical exam-
ination parameters, such as mental status, skin turgor,
pulse quality, capillary refill time, moistness of mucous
membranes, and temperature of the extremities, are
important indicators of hydration status and perfusion.
Periodic auscultation of the lungs and observation of an
animal’s respiratory rate and effort are important for
detecting fluid overload and pulmonary edema.
Although cardiovascular measures (e.g., arterial blood
pressure, CVP, heart rate) are generally useful for moni-
toring fluid therapy, they can be misleading. Arterial
blood pressure and heart rate can be unreliable indica-
tors of cardiac output because of concurrent changes in
www.VetLearn.com
Perioperative Fluid Therapy 109
systemic vascular resistance.17 CVP can
be misleading for assessing optimal
right ventricular preload, especially in
patients with altered ventricular com-
pliance or intrathoracic disease.44
PCV and TP are used to assess the
need for blood products, although
there is a poor correlation between TP
and plasma oncotic pressure in hospi-
talized patients.45 A period of several
to 24 hours is required after hemor-
rhage for the PCV to decrease because
transcapillary refill and renal conser-
vation of sodium and water increase
plasma volume.40 Administering crys-
talloid fluids causes further hemodilu-
tion and may give the false impression
that there is ongoing blood loss.46
Blood urea nitrogen and creatinine levels, in con-
junction with urine specific gravity, can be used to
assess prerenal azotemia. Urinary output is valuable for
monitoring renal function and the adequacy of fluid
because electrolyte imbalances are common in critically
ill patients and can have detrimental effects on cardio-
vascular function.1–3 An arterial blood gas measurement
indicates whether an acid–base imbalance is present
and provides information about ventilation and oxy-
genation, which are important regulators of blood oxy-
gen content and therefore oxygen delivery. Periodic
blood glucose estimations are important in patients sus-
ceptible to hypoglycemia or those requiring dextrose
supplementation.
Colloid osmometry can be used for accurately assess-
ing plasma oncotic pressure subsequent to administer-
ing synthetic colloids, whereas refractometric readings
of total solids are unreliable in animals receiving syn-
thetic colloid therapy.47,48
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Compendium February 2003
ARTICLE #2 CE TEST
CE
The article you have read qualifies for 1.5 con-
tact hours of Continuing Education Credit from
the Auburn University College of Veterinary Med-
icine. Choose the best answer to each of the follow-
ing questions; then mark your answers on the
postage-paid envelope inserted in Compendium.
1. Synthetic colloids should be considered part of the
fluid therapy regimen when
a. a hypotensive patient does not respond to crystal-
loid bolus injections.
b. coagulopathy is present.
c. sepsis is present.
d. renal failure is present.
e. a and c
2. Hypertonic saline can be administered
a. as fast as possible.
b. in patients with severe hypovolemic shock.
c. by any route.
d. without any additional fluid therapy.
e. to achieve a longer duration of intravascular expan-
sion than that possible with colloids.
3. Acute blood loss in a patient with normal PCV and
TP values should initially be treated with
a. isotonic crystalloids at three times the volume of
blood loss.
b. hypertonic saline.
c. a plasma transfusion.
d. whole blood.
e. packed RBCs.
4. Fluid therapy should be continued postoperatively
a. to prevent postoperative oliguria.
b. to correct ongoing fluid losses.
c. on the basis of any remaining deficits and mainte-
nance requirements.
d. to help prevent third spacing secondary to low col-
loid osmotic pressure.
e. all of the above
5. Select the incorrect answer: After an acute hemorrhage,
a. the PCV will fall abruptly in proportion to the
amount of blood lost.
b. the PCV will not change for several hours to 24
hours.
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Perioperative Fluid Therapy 111
c. heart rate and mean arterial blood pressure are
more sensitive indicators of blood loss than is PCV.
d. whole blood should be administered on the basis of
the volume of blood lost rather than the PCV.
e. administration of isotonic crystalloids can give a
false impression of ongoing blood loss caused by
hemodilution.
6. Metabolic changes that can occur with uroabdomen
include
a. hypokalemia, metabolic acidosis, and azotemia.
b. hyperkalemia, metabolic acidosis, and azotemia.
c. hypokalemia and metabolic alkalosis.
d. hyperkalemia, metabolic alkalosis, and azotemia.
e. hyperkalemia and metabolic alkalosis.
7. The IV fluid that should be avoided in the presence of
liver failure is
a. lactated Ringer’s solution (Abbott Laboratories).
b. Normosol-R (Abbott Laboratories).
c. hetastarch.
d. Oxypolygelatin (DMS Laboratories).
e. Ringer’s solution (Abbott Laboratories).
8. For a 20-kg dog receiving IV fluids intraoperatively at
10 ml/kg/hr via a 10 drop/ml dripset, ____________
drops/min should be administered.
a. 1.7 c. 33 e. 10
b. 3.3 d. 200
9. Which statement regarding fluid therapy requirements
with gastric dilatation–volvulus is false?
a. Acute systemic inflammatory response syndrome is
common and causes decreased duration of intravas-
cular volume expansion when crystalloids are used.
b. Colloids are often required because of the presence
of systemic inflammatory response syndrome and
hypoproteinemia.
c. Bicarbonate supplementation is recommended to
correct severe metabolic acidosis.
d. Fresh-frozen plasma administration is recom-
mended to treat coagulopathy associated with dis-
seminated intravascular coagulation.
e. Potassium supplementation of IV fluids is rarely
required.
10. The maintenance fluid requirement for a 5-kg cat is
_____ ml/hr.
a. 100 c. 9 e. 20
b. 220 d. 2