SUBCUTANEOUS FLUID ADMINISTRATION PRESENTED BY MAJ PATTI GLEN

INTRODUCTION -Fluid given under the skin, subcutaneously (SQ), is absorbed into the blood stream and can be used to correct or prevent dehydration. -The most frequent disease for which fluids are given is chronic kidney failure. Dogs with chronic kidney failure pass large amounts of urine and may not feel well enough to drink enough to prevent dehydration. -Subcutaneous fluids may be given a few times a week to supplement the water the dog is drinking in order to prevent dehydration and help flush waste products through the kidneys.   -The most common fluid type given to dogs with chronic kidney failure is Lactated Ringers Solution (LRS).

SUBCUTANEOUS FLUID ADMINISTRATION INDICATIONS Slightly ill and mildly dehydrated animal Slightly prolonged skin tent or capillary refill time Mild diarrhea or vomiting of short duration

SUBCUTANEOUS FLUID ADMINISTRATION TECHNIQUE Three general techniques used to give SQ fluids With a syringe and needle  With a syringe, needle and flexible tubing called an extension set  From a vinyl bag using a solution drip set

GUIDELINES Subcutaneous fluids are tolerated by most dogs 10-20 ml per kg of body weight (5 -10 ml per pound) can be given in one spot (e.g. 50 ml for a 10 pound dog) before moving to another location It usually takes 6 to 8 hours for all the fluids to be absorbed Check to see if the previously administered fluids have been absorbed before giving more fluids Even though the fluids are given on the back, gravity will cause the fluids to accumulate on the belly, so check for residual fluids on the belly before giving more 

PREPARATION The skin is usually not cleansed before inserting the needle (if the dog has a normal immune system, the few bacteria that are pushed under the skin with the needle will be killed by the dog's immune system) Alcohol on a cotton ball can be used to make the hair lay flat so it is easier to see where the hair ends and the skin starts. Alcohol takes about 30 minutes before bacteria are killed, so just swiping the hair with alcohol is not an effective way to kill bacteria. If dog has an abnormal immune system several patches of hair may be shaved and the injection sites scrubbed with an antiseptic solution such as Novalsan® or Betadine® before placing the needle to prevent pushing bacteria under the skin 

NEEDLE SELECTION  The thickness of a needle is measured by gauge (g), the smaller the number, the thicker the needle. An 18 gauge needle is thicker than a 20 gauge needle. Needles may also be different lengths, one-inch and one and one-half-inch are most commonly used.   The plastic hub is the wide part of the needle that attaches to the syringe. 20g needles are most commonly used to give SQ fluids although larger needles (18g) may be used in large dogs and may be used to draw fluid from the container of fluids. Smaller needles (22g) may be recommended for small dogs.

NEEDLE DISPOSAL Needles are packaged in rigid plastic cover and wrapped in paper or plastic to keep them sterile Keep needles in original package until use Do not dispose of needles or syringes in the trash. Keep used needles and syringes in a puncture-proof container such as a biohazard container Don't use the same needle that was placed under the skin to draw more fluids from the container of fluids or bacteria will be introduced into the container of sterile fluids

SYRINGE SELECTION Usually a large (60 ml) syringe is used for fluid delivery The syringe is often packaged in a plastic case Keep the container if the syringe is to be used more than once

SYRINGE DESCRIPTION The syringe is marked in milliliters (ml) and ounces The syringe is marked at 5 ml increments (5 ml, 10 ml, 15 ml, etc.) Each line between the numbers is 1 ml This syringe contains 26 ml of fluid. There is a small air bubble in this syringe. It is not necessary to remove tiny air bubbles such as this one when you are giving fluids SQ.

FLUIDS Fluids are in plastic bags or glass bottles Bags of fluids come packaged in plastic wrapper Remove the wrapper from the plastic bag just before using The fluid type most often given SQ is Lactated Ringers Solution (LRS) Fluids do not contain a preservative, ideally they should only be used only once and then any remainder should be discarded Most veterinarians stock fluids in 1,000 ml bags, a much larger volume than is usually given to a dog at one time

PREPARING INJECTION PORT The neck of the bag of fluids has 2 ports; the injection port that is covered with a rubber stopper and a port covered by plastic (blue) in which the spike of a solution set is inserted Clean the rubber stopper of the injection port with an antiseptic solution such as Novalsan® (chlorhexadine) or Betadine® (povidone iodine) before inserting the needle, if more than one puncture will be made through the stopper. Alcohol takes about 30 minutes of contact before bacteria are killed, so it is not a good solution to use. Always use a sterile needle to draw fluids from the sterile container Do not use the same needle to give the fluids to the dog, and then place that needle back into the fluid container as it will become contaminated with bacteria from the skin. 

NEEDLE PLACEMENT INTO FLUID BAG Remove plastic cap from needle Place tip of needle into injection port Needle must be inserted into the center of the rubber stopper The injection port itself is held so the needle is inserted straight into the injection port.

INCORRECT NEEDLE PLACEMENT This needle is placed off-center and is puncturing the injection port

DRAWING FLUID INTO SYRINGE Draw back on the syringe plunger while holding the syringe barrel steady so the needle does not pull out of the fluid bag Fill the syringe to the volume desired Do not fill a 60 ml syringe past 50 ml as the plunger may accidentally be pulled out of the barrel of the syringe and spill the fluid

RE-DRAWING Replace the 18 g needle with a 20g needle When you have given the first syringe full of fluids, change back to the 18g needle to draw another syringe full and change back to the 20g needle to inject the dog Keep the plastic caps on the needles as you exchange them. Use one new 18g and one new 20g needle each time you give fluids to the dog; alternating needles between syringe fulls of fluids. 

ADMINISTERING THE FLUID Pinch up a fold of skin anywhere along the neck or  back using your left hand if you are right-handed Use your right hand to place the needle that is attached to a 60 ml syringe, into the skin fold along the long axis of the fold If you place the needle in the opposite direction, across the skin fold, it is more likely that the needle will go through one fold of skin and out the other fold of skin

ADMINISTERING THE FLUID Before injecting the fluid, pull back on the plunger of the syringe. If air bubbles appear in the syringe, the needle has gone through both folds of skin and you are sucking room air into the syringe. Remove the needle from the skin and try again. If you get blood, the tip of the needle is in a blood vessel. Remove the needle and try again.

ADMINISTERING THE FLUID Once the needle is correctly placed let go of the skin fold and push the plunger to inject the fluids The plunger can be pushed using one hand by holding the syringe between your fingers and pushing the plunger with the thumb of the same hand   The other hand can be used to steady the syringe or comfort the pet

ADMINISTERING THE FLUID Alternatively, hold the syringe in one hand and push the plunger with the other The fluids can be injected as fast as the plunger can be pushed

ADMINISTERING THE FLUID If the needle is not directly attached to the syringe, but is attached to a flexible piece of tubing (an extension set) first, the dog can move around a bit while the fluids are being injected. The extension set will be packaged in a plastic/paper wrapper. Remove from wrapper, remove the white plastic cap from one end and firmly place on the tip of the syringe. Remove the cap on the other end and place into the hub of the needle. The two ends are different, the female end fits over the tip of the syringe. The male end fits into the hub of the needle.

ADMINISTERING THE FLUID The needle attached to the extension set is inserted into the injection port Draw the prescribed amount of fluid into the syringe Replace the 18g needle with a 20g needle and recap the 18g needle with the plastic needle cap Push some of the fluid through the tubing to evacuate air from the tube, a procedure called priming.

ADMINISTERING THE FLUID   The syringe containing the fluids is laid on the table.  Pinch up a fold of skin anywhere along the neck and back using your left hand if you are right-handed. Use your right hand to place the needle into the skin fold along the long axis of the fold. Pull back on the plunger of the syringe. If air bubbles appear in the syringe, the needle has gone through both folds of skin and you are sucking room air into the syringe. Remove the needle from the skin and try again. If you get blood, the tip of the needle is in a blood vessel. Remove the needle and try again

ADMINISTERING THE FLUID Once you have checked that the needle is correctly placed, let go of the skin fold and push the plunger to inject the fluids The plunger can be pushed using one hand by holding the syringe between the index finger and middle finger and pushing the plunger with the thumb of the same hand 

ADMINISTERING THE FLUID If this is difficult, hold the syringe in one hand and push the plunger with the other. The yellow X marks the site the needle is entering the skin.

ADMINISTERING THE FLUID The third method to give SQ fluids is to attach a solution drip set to a bag of fluids Remove the solution set from the plastic/paper wrapper Both ends are covered with plastic caps. After removing the cap, the male end fits into the hub of the needle The white spike is punctured into the spike port of the bag of fluids after removing the plastic tube that covers the spike

ADMINISTERING THE FLUID The spike port on the bag of fluids is covered by a blue plastic cover This cover is pulled off The cover is tightly covering the spike port and you have to pull firmly to remove it

ADMINISTERING THE FLUID The white spike on the solution set is pushed into the spike port. Hold the spike port in your left hand to guide the spike straight into the port. If you push the spike in at an angle, it may puncture the bag of fluids.

ADMINISTERING THE FLUID Attach a needle to the other end of the solution set

ADMINISTERING THE FLUID The plastic tubing has 2 clamps that must be opened to allow fluid to flow  The dark blue pinch clamp has a tapered slot, the tubing is pushed to the widest part of the slot to open and pushed to the narrowest part of the slot to stop fluid flow The light blue clamp is a roller clamp. Use your thumb to roll the white disk up, toward the solution chamber to open and in the opposite direction to close The fastest flow of fluids occurs with both clamps fully open Before placing the needle in the SQ, open the clamps and let fluid flow until the air is evacuated from the tubing You will see drops of fluid drop in the drip chamber when the clamps are open. If the drip chamber fills with fluid so that you cannot see the drops forming, turn the drip chamber upside down and squeeze some of the fluids back into the bag

ADMINISTERING THE FLUID The skin is tented and the needle inserted along the long axis of the fold. You cannot suck back to check for air so watch the site at which the fluids are entering the skin fold to make sure the hair isn't getting wet suggesting the needle is incorrectly placed

ADMINISTERING THE FLUID The fluids can be dripped into the SQ space as fast as the drip will go The higher you hand the bag, the faster the fluids will flow

ADMINISTERING THE FLUID The bag can also be rolled up and the fluids squeezed out of the bag for faster delivery If instructed to use the same fluids and solution set for more fluids later, place a clean needle covered by its plastic cover on the end of the solution set 

REFERENCE http://www.vetmed.wsu.edu – giving subcutaneous fluids to a dog