Learn how IDEXX is enhancing the lives of animals, people, and the planet.

IDEXX: Contributing to something bigger

Pet Releaf, the market-leading hemp health brand for pets, has released Sentesa, a hemp-based supplement featuring a triactive formula. Sentesa was developed by veterinarians, exclusively for veterinarians and specially made to help manage canines’ inflammatory response, calmness, joint flexibility and mobility, and discomfort, according to a company release. Proved safe and fast acting to guarantee efficacy, Sentesa’s triactive formula consists of cannabidiol (CBD), β-caryophyllene, and caprylic acid.

"We knew from our veterinary partners that there is an unmet need for data-driven product development in the hemp space. We focused on delivering products to the veterinarian that can safely and effectively manage their patients’ longterm health and well-being,” says Alina Smith, CEO and cofounder of Pet Releaf, in this 

. “We are proud to offer Sentesa as a safe, effective, and natural alternative to help bridge a needed gap in pet care.”

Made with the highest-quality ingredients and manufactured in a cGMP (Current Good Manufacturing Practice) facility, Sentesa has undergone testing in a third-party accredited laboratory and evaluation in clinical studies.

“It can be difficult to treat pets through chronic diseases and long-term pain. Incorporating Sentesa into veterinary practices can help pets suffering from a multitude of ailments in a more all-natural way, without the harmful adverse effects that may be caused by pharmaceuticals,” says Joseph Rosentel, DVM, PhD, MS, vice president of product development and supply chain, in the release. “With the data-driven approach to development, completed safety and PK study, and an ongoing field safety and efficacy study, we are thrilled to offer the veterinarian a new option for the treatment of their patients.”

The capsules are available in 2 sizes: for small dogs (11-33 pounds) and medium/ large dogs (33+ pounds). Sentesa for small dogs contains 10 mg of CBD, 10 mg of β-caryophyllene, and 10 mg of caprylic acid. Sentesa for medium/large dogs contains 30 mg of CBD, 30 mg of β-caryophyllene, and 30 mg of caprylic acid

Articles

Hemp-based capsules that promote patient health and healing are the first product
of Pet Releaf’s Professional Line for veterinarians.

Pet Releaf debuts professional product line with Sentesa

Digital marketing and communication have evolved exponentially over the past few years and have been cemented as pillars of client retention and a quantifiable revenue stream in the veterinary industry. Meeting clients where they are—often on their mobile devices—with pertinent information tailored to their needs is essential to succeed in the current climate. In fact, the veterinary software industry is rapidly growing and is expected to surpass $2 billion by 2027.

 But not all communication services are created equally.

Too often, hospital owners and practice managers are overwhelmed with the software options available or find themselves constrained by the generic templates supplied by outdated systems. Providing timely, appealing client communications should not require a Master’s degree in IT. 

dvm360® recently spoke with 3 experienced veterinary professionals to pinpoint common problems that practices encounter with subpar communication systems, while also shedding light on how AllyDVM has become an asset to their businesses.

Mending the communication gap between veterinary professionals and their clients. 

A 2018 study conducted by the Partners for Healthy Pets— a collaborative alliance led by the American Animal Hospital Association and the American Veterinary Medical Association—revealed significant disconnects between the viewpoints of pet owners and practitioners, particularly when it came to what occurred and was discovered during a physical exam for their pets, including pain assessments and dental exams.

Clients do not always absorb the pertinent information relayed during an appointment or they fail to properly recall the recommended next steps.

: Enhancing staff-client communications within the exam room setting is important, but having a follow-up tool to reiterate the services performed and veterinary recommendations could have a tremendous impact on client comprehension and compliance. For veterinary professionals who have struggled with this for years, it is easy to understand why AllyDVM’s direct messaging feature is quickly becoming one of the most popular components of the suite. Beyond sending appointment reminders—which it does seamlessly—it provides another channel of communication between the client and practice.

“More and more, our clients want instant communication and a quick turnaround of information. It is very easy to do that with AllyDVM. A client can send us a request and we can get right back to them,” says Patti Christie, CVT, CVPM, the practice manager at Minnehaha Animal Hospital and Pet Doctors Animal Clinic in Minneapolis, Minnesota. “Clients also really appreciate that they have the ability to connect with us without having to make a call.”

 veterinary hospitals in central Illinois— Greenhaven Animal Clinic, Prairiehaven Animal Hospital, and Best Friends Animal Hospital—says he cannot place a high enough value on strong practice-client communications. “It is so critical today. It’s not just the younger generations that use the feature; everybody likes texting.” 

The client service representatives and technicians at his hospitals regularly use the direct messaging/texting feature to follow up with clients after a visit. “Our clients love the fact that it is relatively quick and easy for us to check in with them,” he adds. “It helps with client communication and retention, as well as bonding the client to the clinic.”

Practices lose a large amount of potential income when client compliance and retention lapse. 

Pet parents are notorious for missing the recommended schedules for vaccines, annuals, and other health services. This is detrimental to a patient’s health and could prevent the early diagnosis of treatable diseases.

 There are steps practices can implement to increase client compliance for routine wellness visits and vaccinations. These, in turn, have evident effects on the bottom line. AllyDVM’s client retention calendar makes it simple for hospitals to notify clients when their pet is due for a wellness visit and encourages multi-pet homes to schedule all of their exams at once.

“The retention calendar was a huge [selling point] for us because it is so helpful to show us the other pets in the household that are due for exams. I do not know how many times we have had clients get mad at us for not letting them know their other pets were due to be seen, too,” explains Kerry Lueker, CVT, hospital manager at Crest Hill Cat and Dog Clinic in Joliet, Illinois.

Dr. Armbruster utilizes the retention calendar to forward book all appointments. “If you are in for a routine wellness exam, we are making your exam appointment for 6 months from now before you leave. Or if it is a sick patient, then you are getting booked a week or 2 out, depending on the doctor’s recommendation.”

minder system can be programmed to send automatic reminders. This has helped practices decrease the number of no-shows and last-minute cancellations. “From a convenience standpoint, you’ll get a reminder text that your appointment is coming up. It is nice that the feature is 

customizable, too. We can set whether the reminder text goes out 2, 3, or 4 days in advance to let the client know they have a pending appointment,” Dr. Armbruster says.

Generic email communications are left unread; valuable information never reaches clients. 

Veterinary clients are savvy. They can recognize when a blanketed email campaign lands in their inbox and can generally infer by the subject line if the topic is of interest. It is imperative that hospitals stand out from the dozens of emails that people receive on a daily basis. It is counterproductive to send an email about senior bloodwork testing to an entire database when it only applies to a small segment of the clientele. Similarly, households with only cats are not interested in discounts on canine heartworm preventatives.

Make your communications matter. Each message should be valuable to the intended recipient. AllyDVM has proven to be one of the leaders in providing filtering capabilities. Users can target the right client segment—by species, procedure, age, disease, etc.—at the right time, automatically.

“We can target information relative to senior pets, for example,” Christie explains. “So we can target the patient individually and use that opportunity to provide information as well as give them a reason to set up an appointment for their pet.”

Incorrect or invalid client contact information leads to otherwise avoidable miscommunications. 

For Lueker, clients not receiving intended phone calls and reminders was one of the biggest challenges her hospital faced. Previous communication software missed the mark in alerting her of errors within the system. “We didn’t have a way to track that before. Our old software would alert us that 10 emails did not get sent out, but not which specific clients.”

AllyDVM is designed to highlight missing information or possible contact errors. “It will show me if someone 

put in ‘Yahoo’ with an extra ‘o’ or if someone spelled something wrong,” Lueker explains. Fixing those mistakes is simple and has a profound impact on ensuring intended communications are received.

“One thing that is really nice about the feature is that it also tells you how much you are potentially missing in revenue by not getting the right information, like the correct email or telephone number,” Christie adds. Similarly, AllyDVM has tools to reflect the revenue gained by taking advantage of the retention calendar features.

Box stores and commercialized websites are steering clients away from hospitals’ dedicated online stores and pharmacies. Practices may feel they do not have the means to compete with retailers.

 Recently, AllyDVM launched its buzzed-about manufacturer partner program to complement the communication services that practices have grown to depend on. The Synergy Partner Program is a turn-key marketing tool kit that includes simple, automated email campaigns. The email capabilities also include money-saving offers from some of our top manufacturer partners in the industry, designed to drive pet owners into the practice to purchase products.

Lueker has found the program particularly helpful in getting clients to act on offers related to heartworm medications. Clients would call as a result of receiving the email, and the staff provided further information about the product and how it could benefit their pets. “We’ve gleaned quite a lot of revenue just from getting them to come in for ProHeart®,” she explains.

Her practice had a similar experience after sending a Synergy Partner Program email regarding Simparica Trio®. “A lot of people were waiting for it to come out since it is an all-in-1. As soon as they received the email, they were on the phone calling us to see what they needed to do next for their pet to receive it.”

Clients crave ease and instant gratification. The standard routine of calling a clinic, being placed on hold, and then trying to sync schedules based on availability does not fit those criteria.

 AllyDVM’s live bookings calendar can be easily added to a hospital’s website or patient portal, the latter of which syncs directly to a hospital’s practice management system. 

“Our clients love it,” Lueker says. “They can access pet health records, set up appointments, request refills, and view loyalty points. There are also hot buttons that will take them over to our online pharmacy, website, Facebook, etc.” Additionally, it provides clients with control over finding an appointment that works best for their schedule

“With AllyDVM it shows clients the actual days and times that are available,” she adds. “Our old software did not show that, therefore, people would be requesting appointments for the next day and then getting upset with us that we could not fit them in.”

The calendar also shows availability based on appointment type. “For example, our sick appointments are longer visits,” explains Lueker. “So if they are requesting a sick appointment, but we only have a 20-minute spot open versus a 40-minute slot, it will not even show them that slot. It will just show them the 40-minute ones.”

When it comes to finding a client-communication service, don’t settle. Your practice’s reputation and revenue are on the line. 

“AllyDVM is one of the most important tools we have in our toolbox, quite honestly,” Christie explains. “It was really well designed by people who certainly understand the industry and the needs we have."

WORKING TOGETHER TO HELP YOUR PRACTICE SUCCEED Leverage all of the offerings and programs from MWI to help you improve compliance, grow revenue, and support pet health and happiness. www.mwiah.com/compliance/dvm360

Allied Market Research. Veterinary Software Market Statistics, Growth Analysis and Forecast - 2027. Allied Market Research, 2019. www.alliedmarketresearch.com/ veterinary-software-market#:%7E:text=The%20global%20 veterinary%20software%20market,6.1%25%20from%20 2020%20to%202027. Accessed May 14, 2021. 

2. An American Animal Hospital Association-American Veterinary Medical Association White Paper. The Opportunity Pet Owners Don’t Always Hear What We Think We Tell Them (and How to Fix That). Partners for Healthy Pets. 2018. Accwww.aaha.org/globalassets/04-practiceresources/The-Opportunity. Accessed May 14, 2021.

With the expansion of digital marketing and communication in recent years, the number of software options out there can overwhelm practice managers and hospital owners. Find out why these 3 veterinarians prefer AllyDVM. 

The veterinary ally: A comprehensive communication solution

As we're amidst the dog days of summer, we continue to offer the most current, intriguing veterinary news and information.

 that measures pet temperatures under the foreleg or hindleg and swiftly sends the results to practice management software.

recently acquired its third acquisition of the year

, Central Animal Clinic, expanding its new veterinary clinics to 6.

 to find out what's causing this Frenchie with intervertebral disc disease skin lesions. 

 as the new CEO, bringing 15 years of scientific and commercial expertise within the animal health industry to the team.

From a smart cat water bowl to online scheduling platforms, here's a 

rundown of the latest veterinary products

Stay tuned on social media and dvm360.com for more veterinary news.

News wrap up: This week's veterinary headlines, plus first non-invasive pet thermometer 

Veterinary practice discovery and booking platform

VetVet is a website that helps clients search for and book appointments with veterinarians who best meet their pet’s needs. Because each veterinarian has unique training and experience, this platform hones in on the complementary professional for new patients. The digital platform’s booking and onboarding capabilities help to save time for both clients and office staff members. By digitizing booking and helping to fill empty appointment slots, VetVet improves practice efficiency and helps drive increases in revenue.

Purina Pro Plan Veterinary Supplements Calming Care

Purina Pro Plan Veterinary Supplements Calming Care for cats contain 

 (BL999), a probiotic strain shown to help promote calm behavior in felines. Calming Care aids cats in managing changes in routine and location while encouraging positive behaviors (eg, playing, seeking out social contact). Because diet-related changes in gut microbiota can influence the brain via the gut-brain axis and therefore, may influence anxious behaviors, BL999 targets the gut-brain axis to alter anxious behavior. Calming Care is packaged in boxes of 45 sachets. It should be supplemented daily for at least 6 weeks to evaluate efficacy.

Felaqua Connect is the smart cat water bowl that provides insights into drinking behavior by connecting with your cat's microchip, highlighting changes which may otherwise be missed. Its wide, shallow bowl presents water in a way that is more visible and appealing to your cat. Felaqua Connect delivers clean, fresh water and automatically refills from the reservoir—no recirculating water or filters. Felaqua Connect is battery operated, cable free, and dishwasher safe. Pair Felaqua Connect with the Sure Petcare App which indicates how often, when, and how much your cat drinks and receive notifications when the water needs to be changed.

Launched by Walmart, this veterinarian-formulated pet food line for dogs and cats complements the 9-year-old Pure Balance brand. Deemed “super-premium,” the 9 new diets are made with either chicken, salmon, or turkey as the first ingredient. This formula contains natural ingredients, plus added vitamins, minerals, and other nutrients, and is free of artificial colors, flavors, or preservatives. The food line includes Pro+: Puppy, Senior Dog, Weight Management for Dogs, Weight Management for Cats, Small Breed for Dogs, Large Breed for Dogs, Kitten (wet and dry), Senior Cat, Sensitive Skin & Stomach for Cats.

This clinically tested smart axillary thermometer is the first-ever to measure feline and canine temperature under the foreleg or hindleg while immediately sending results to practice manager software. In partnership with Vetspire, a cloud-based veterinary practice management system, Mella Pro uses Bluetooth connectivity to provide the first end-to-end integrated vital signs measurement on both the veterinary and human market. It uses various temperature sensors, millions of patient records, and machine learning to calculate an accurate reading. Mella Pro displays the result within 10 to 15 seconds and can be used both at home and the clinic.

Vetster connects pet owners to thousands of licensed veterinarians prepared to offer the best online services through video chat appointments 24/7. This unique platform allows users to search for available veterinarians in their area and find a match within seconds—no downloads required. From initial concern to diagnosis to product delivery, receive prescriptions delivered to your door in 2 days or less. Veterinary professionals interested in working for the platform can set their own hours and are quickly compensated for all completed appointments through the convenient payout processing. Vetster can be accessed on your computer, tablet, or mobile device.

This bivalent canine flu vaccine by Zoetis effectively protects canines against both highly contagious H3N2 and H3N8 strains of canine influenza virus (CIV). This vaccine is approved for use in healthy dogs age 8 weeks and older. A study examining efficacy revealed that the vaccine not only protected dogs from disease, but also appeared to assist in decreasing the number of days for shedding the CIV H3N2 virus. This convenient vaccine protects dogs from both known CIV strains, thus, helping to protect canines overall in the community by increasing herd immunity. Dogs should initially receive 2 doses administered 3 weeks apart. The need for an annual booster vaccination has not yet been established; consultation with a veterinarian is recommended. Available in 25 x 1-dose packages.

If your area is in the midst of a CIV outbreak, go 

Vetstoria helps practices save time, enhance service, and grow by providing pet owners the ability to book appointments conveniently from the clinic’s website. These appointments are then synced straight into the practice management system calendar in real-time. Including a user-friendly dashboard that enables you to set your preferences, this platform helps to control availability and replicate your existing booking workflow. You can embed Vetstoria on your website or share booking links in email campaigns, text messages, social profiles, and much more. Plus, accept payments at the time of booking and easily send automated appointment reminders. Some Vetstoria features include:

Real-time sync with your existing calendar

Here's our regular rundown of new and notable veterinary products.

dvm360 product report: Smart cat water bowl, plus a noninvasive pet thermometer and more   

CityVet—a leading network of 20 veterinary-owned practices providing exceptional pet care based in Dallas, Texas—recently announced its acquisition of Central Animal Clinic, located in Cedar Hill, Texas and known for its specialization in small animal medicine for over 30 years.

According to a company release, this transaction serves as CityVet’s third acquisition within the year and broadens its new veterinary clinics to 6.

“We are excited to join the CityVet network. They are paving the way for our associate veterinarian to have ownership in the clinic and to grow as a leader,” says Chris Rose, DVM, founder of Central Animal Clinic, in the release.

“CityVet believes in putting people at the center of everything they do, and our team looks forward to this next chapter. Their facilities are state of the art, and I can’t wait to see the remodel of our clinic,” he adds.

Over the last 20 years, CityVet’s expansion has been centered around developing a de novo model and offering a unique opportunity for lead veterinarians to have ownership in their hospital. Additionally, Central Animal Clinic will be the third non-branded clinic in the company’s portfolio.

“Dr Rose and his team have a well-established clinic in Cedar Hill with a strong reputation as a trusted veterinary partner. Their clients and staff will benefit from our scale and the value-added services we will provide in close partnership with Dr. Rose,” says David Boguslawski, CityVet CEO, in the release.

“We have a plan to make significant building updates and are excited to help grow the legacy Dr. Rose and his team established in Cedar Hill,” he continued.

The terms of the transaction were not disclosed. This acquisition is effective as of July 15, 2021. For more information about CityVet and its mission, go 

This transaction expands the company’s new clinics to 6 and marks its third acquisition within the year.

CityVet acquires Central Animal Clinic

Fluid therapy is a dynamic topic in the medical field. In the 19th century (and for many centuries prior), medical doctors thought bloodletting was a reasonable treatment for a variety of conditions. Fast-forward to the 1950s and beyond, when the mainstay of treatment became aggressive intravenous (IV) fluid boluses. Until recently, fluid boluses were routinely given to most patients in an emergency setting. However, recent studies in the human and veterinary fields have demonstrated that aggressive fluid therapy is not always beneficial and may often be detrimental to our patients. This article will review the fundamentals of fluid therapy, how to approach critical patients with regard to fluid therapy, and the consequential role of the endothelial glycocalyx.

Calculating maintenance fluid requirements

Defining maintenance rate is often a point of contention. Some sources state the general rule of thumb for maintenance requirements should be 40 to 60 mL/kg/day. The problem with this estimation is that it is less accurate in very small and very large patients. Maintenance requirements are based on body surface area, which is a logarithmic measurement, not linear.

A more accurate measurement is based on metabolic rate; it is estimated that 1 kcal = 1 mL H

O. The simplest method to calculate basal metabolic rate or basal energy requirement (BER) is: [30 × BW(kg)] + 70. This has been shown to be accurate for patients over 2 kg and under 100 kg. In patients outside this range, a more accurate calculation is [BW (kg)^0.75] × 70. Estimating their maintenance based on BER alone will be slightly under their maintenance needs because BER assumes no activity. Consequently, using a multiplier between 1.2 and 2 may better approximate the true metabolic expenditure of the patient, and therefore their maintenance energy requirements.

However, given that fluid overload is more detrimental to a patient than being slightly dehydrated,

the author’s preference is simply to use BER as the maintenance rate, especially because more fluid will be added to the total rate in order to account for replacing the estimated fluid deficit as well as ongoing losses. Any formula you come across for estimating maintenance fluid rates is just that—an estimate. This is why frequent monitoring of patients receiving IV fluids is so crucial.

Although IV fluid therapy is the most common route for hospitalized patients, there are multiple routes by which fluid therapy can be administered. Choosing which route depends on the patient, their specific needs, and their disease state.

Per os fluids are often forgotten and underrated. As long as there are no contraindications, such as vomiting or regurgitation, free access to water should always be allowed. In addition, fluids can be administered via a nasogastric tube if the patient is having one placed for other purposes.

 A classic example in which oral fluids can be very helpful in a critical setting would be a puppy with parvovirus enteritis (typically these patients are on CliniCare or another type of feeding with a high water content, but additional water boluses of 20-30 mL of lukewarm water can be given q2-4h.

Not only do enteral fluids stimulate the intestinal tract, but this is also the safest route of fluid administration in terms of avoiding fluid overload. In a patient with hypoalbuminemia, a heart murmur, or other comorbidities that may exacerbate hypervolemia, oral fluid administration should be considered. Oral fluids are contraindicated in any patient that has recently been vomiting or regurgitating.

Administering fluids subcutaneously is reasonable for rehydration; however, this is not an appropriate route of administration for patients exhibiting any signs of shock. Only isotonic solutions such as lactated Ringer’s solution (LRS) or Normosol-R (NSR) can be used, and they should be free of additives. The recommended dose is typically 30 to 40 mL/kg but can be higher in younger animals and exotic species. Subcutaneous fluids are contraindicated for any hypovolemic patient.

In any patient that is exhibiting signs of shock, not eating or drinking normally, anesthetized, or showing significant acid-base or electrolyte abnormalities, IV administration is the route of choice. IV access allows rapid volume resuscitation, correction of electrolyte abnormalities, and restoration of euglycemia in hypoglycemic patients. However, IV fluids are contraindicated in patients with congestive heart failure or any noncardiogenic causes of pulmonary edema. IV fluids should be used cautiously in patients with cavitary effusions, hypoalbuminemia, oliguric or anuric renal failure, heart murmur or gallop rhythm, or any other comorbidities that may contribute to fluid overload.

In patients for which IV access cannot readily be obtained (ie, very small patients or some exotic species) and that are also too ill for subcutaneous fluid therapy, intraosseous fluids should be considered. After volume resuscitation using an intraosseous catheter, it is often possible to place an IV catheter, because improved perfusion will expand peripheral vessels.

Crystalloids are the mainstay of fluid therapy. Crystalloids consist of salt in water. Balanced crystalloid solutions also contain electrolytes and a buffer. Crystalloids rapidly redistribute out of the vascular space and into the interstitial space. It is estimated that 75% to 80% of the volume administered will move out of the vascular space within 30 to 60 minutes after administration. Larger volumes of crystalloids are required to have the same hemodynamic effect on a hypovolemic patient as a smaller volume of hypertonic saline (HSS) or a colloid solution. There are many crystalloid options available, but this article will focus on normal saline, balanced isotonic solutions, and HSS.

Normal saline (0.9% NaCl) used to be the mainstay of crystalloid fluid therapy in human medicine. However, studies have shown that normal saline may result in hypernatremia and hyperchloremia, as well as metabolic acidosis. It is important to note that normal saline is not a physiologic solution; it contains far more sodium and chloride than plasma and is acidifying by nature. Studies have also shown that hyperchloremia can lead to impaired renal function and an increased need for renal replacement therapy.

In veterinary medicine, there are several circumstances in which normal saline can be useful. The first is in hypercalcemic patients, because it promotes calciuresis (sodium competes with calcium for tubular resorption). The second condition is in patients with hypochloremic metabolic alkalosis (which is rare but most commonly associated with an upper gastrointestinal obstruction). Furthermore, normal saline can be used to slowly correct severely hypernatremic patients with either a chronic condition or suspected chronic hypernatremia (correction of sodium abnormalities is complex and the intricacies of such are beyond the scope of this article). Normal saline should not be considered the first-choice crystalloid for IV fluid therapy, and it is the author’s belief that it should not be used outside of the 3 circumstances listed above.

Balanced crystalloid solutions are the most physiologic in nature, meaning their composition is most similar to that of plasma, in terms of content and tonicity (290-310 mOsm/L). They contain electrolytes as well as a buffer (lactate, acetate, or gluconate). The most commonly used isotonic crystalloids are NSR, LRS, and Plasma-Lyte (P-lyte). NSR and P-lyte have a sodium content most similar to that of plasma (both are 140 mEq/L), whereas LRS is slightly hypotonic (130 mEq/L with a tonicity of 273 mOsm/L).

LRS is contraindicated in patients with severe liver diseasebecause hepatic function is necessary to convert lactate to bicarbonate. If liver function is impaired, the use of LRS may result in lactic acidosis.

HSS differs from other crystalloids in that it is a good plasma expander. HSS typically comes in a solution of 5% to 7.5% sodium chloride. Hypertonicity causes water to shift from the interstitial and intracellular spaces into the intravascular space, which increases plasma volume. The volume of HSS required to produce specific hemodynamic effects is significantly lower than the volume of crystalloid required to produce the same effects, so HSS is ideal for low-volume fluid resuscitation.

HSS should only be given to patients with normal interstitial and intracellular hydration. For example, HSS is useful for patients with acute hemorrhage or hypovolemic shock secondary to trauma; however, it would be a poor choice in a markedly dehydrated cat with renal failure. The recommended dosing is 3 to 5 mL/kg in dogs and 2 to 4 mL/kg in cats, usually given over 10 to 20 minutes. It is important to keep in mind that additional crystalloids should be given after the administration of HSS to avoid subsequent hypernatremia and interstitial dehydration.

HSS has also been used in patients with traumatic brain injury to reduce intracranial pressure. There have also been studies showing the beneficial effects of HSS on microvascular perfusion and oxygen delivery for patients in hemorrhagic shock. The literature is mixed in terms of the effect of HSS on coagulation; one study published in 2015 showed impaired platelet function and whole blood coagulation following HSS administration,

whereas a study published in 2020 showed no effect on coagulation parameters.

A single bolus given to stabilize an actively hemorrhaging patient, prior to the administration of blood products, is unlikely to have significant effects on coagulation, and should be considered in such patients for low-volume resuscitation.

Colloids contain high molecular weight particles, which cannot cross an intact vascular barrier, and thereby provide significant oncotic support and volume expansion. Therefore, this should reduce the development of interstitial tissue edema, because the fluid remains in the intravascular space. Colloids can be further classified into natural or synthetic colloids.

Hydroxyethyl starches (HES) are the most commonly used synthetic colloid in veterinary medicine. Dextrans and gelatins are the other 2 classes, but they are used less frequently. Hetastarch is the most commonly used HES in veterinary medicine. The benefits of using a synthetic colloid such as hetastarch include maintaining colloid osmotic pressure, low volume resuscitation, rapid intravascular expansion, and a volume of distribution that not only stays within the intravascular space but lasts much longer than it would with crystalloids (up to 6 hours). However, despite these advantages, there is no clinical evidence to support the use of synthetic colloids to reduce morbidity and mortality. In fact, most studies report increased mortality with the use of synthetic colloids, and the most significant adverse effects (AEs) include acute kidney injury and coagulopathies. Other less common but potentially severe AEs include allergic reactions, hepatopathy, pruritus, and reticuloendothelial dysfunction.

 In human medicine, synthetic colloids have fallen out of favor for the treatment of septic shock, as there have been multiple studies showing increased mortality with their use. 

Synthetic colloids can still be considered but must be used with caution and should be avoided in any animal with impaired renal function, coagulopathy, hypervolemia, or heart murmur. The most recent Surviving Sepsis Campaign

recommendations in human medicine advise against the use of synthetic colloids in patients with sepsis or septic shock; it is no longer common practice for veterinarians to use synthetic colloids in such patients. If used, the recommended dose range should not exceed 20 mL/kg/d to minimize or prevent any AEs. This can be given either as a continuous rate infusion or in incremental boluses of 5 mL/kg. In cats, the dose should not exceed 10 mL/kg/d and boluses can be given in increments of 2.5-3 mL/kg/d. Frequent monitoring of patients receiving synthetic colloids is imperative.

In human medicine, 4% albumin is a mainstay of therapy in critically ill patients for a multitude of reasons beyond its colloidal benefit: it helps to maintain and restore the integrity of the endothelial glycocalyx, has anticoagulant properties, protects against oxidative damage, and plays a role in serum drug and hormone binding. Unfortunately, a readily available, species-specific albumin is difficult to obtain in veterinary medicine. Lyophilized canine-specific albumin is sporadically available, and in a small study of 7 dogs with septic peritonitis

 it showed improved outcomes. Given the lack of availability of canine-specific products, human serum albumin (HSA) has been used in veterinary species as well. However, some reports have shown severe and even fatal type III hypersensitivity reactions in dogs treated with HSA. Therefore, the use of HSA is controversial and not widely accepted at this time.

Blood component therapy such as fresh frozen plasma (FFP) can also be considered for colloidal support. Although FFP is typically used for patients with coagulopathies or acute hemorrhage, it also provides other components such as immunoglobulins and albumin, among other plasma components. Although FFP does contain albumin, it takes a significant volume of FFP to increase the concentration of albumin; it is estimated that 45 mL/kg will increase the albumin concentration by 1 mg/dL, and the normal dose for a coagulopathic patient is 10 to 20 mL/kg. Not only is this often cost prohibitive, but administering this volume increases the risk of transfusion-associated AEs. These include transfusion-associated circulatory overload (TACO), transfusion-related acute lung injury (TRALI), and febrile nonhemolytic transfusion reactions.

Part 2: Making a fluid therapy plan and monitoring patients on fluids

Fluids are drugs, and we should put just as much thought into fluid therapy for every patient as we do into administering any other medication. There are 4 main questions to ask yourself when formulating a fluid plan:

Treatment of hypovolemia is addressed in more detail in the next section. Once a patient is volume resuscitated, you can consider the latter 3 questions. If you have given fluid boluses, a repeat physical examination and blood work are helpful to reassess hydration status. For example, if the patient arrived with a packed cell volume/plasma total solids (PCV/TS) value of 65/9.0, then rechecking this parameter will help you know how much progress has been made in correcting the dehydration.

Many parameters can be used to determine the degree of dehydration (see 

 below). The volume to be replaced can be calculated as [weight in kilograms × % dehydration] × 1000 = volume in liters to be replaced. Dehydration should be corrected over the first 12 to 24 hours; however, this should be extended to 36 to 48 hours in patients more susceptible to fluid overload (especially cats). Always keep in mind that if a problem happens slowly, it should be corrected slowly, and that dehydration and hypovolemia are not synonymous. Giving a fluid bolus for a patient who is dehydrated but not hypovolemic is contraindicated; it will not restore their interstitial deficit any faster and will damage the endothelial glycocalyx in the process.

Once you have calculated an estimated fluid deficit, estimate the patient’s maintenance needs as discussed above. Be sure to take into account any comorbidities, such as known cardiac disease, hypoalbuminemia, or any other factors that may predispose the patient to fluid overload. When in doubt, err on the side of caution and choose a lower rate (you can always give more fluid—it is much harder to take it back).

Finally, estimate the patient’s ongoing losses. If the patient has a urinary catheter in place, this can easily be used to quantify urine output every 4 to 6 hours. However, it is more difficult to estimate other kinds of losses, such as those from the intestinal or respiratory tract. In smaller patients, it may be helpful to weigh used potty pads and subtract the original weight of the pad (the difference in kg is equal to the volume lost in liters). One of the easiest ways to measure fluid balance is simply to weigh the patient every 12 hours.

Other parameters that should be monitored include vital signs and mentation, blood pressure, PCV/TS, renal values, urine-specific gravity, blood gas and base deficit, serum lactate,

 and AFAST/TFAST (abdominal and thoracic focused assessment with sonography for trauma, triage, and tracking, especially if there are concerns about third spacing).

Once you have determined these parameters, you can calculate your fluid rate as follows:

fluid rate = (volume of dehydration in liters/number of hours to correct dehydration) + (maintenance rate) + (estimated ongoing losses). Once you have a final rate, be sure to ask yourself whether the fluid rate is appropriate for your patient’s weight. In general, it is not recommended to exceed rates of 2 to 3 mL/kg/h in cats or 2 to 6 mL/kg/h in dogs.

The most important part of making a fluid plan is to reassess. Fluid therapy is not one-size-fits-all. Pay attention to the parameters listed above and adjust as needed. For instance, if a patient comes in with a PCV/TS of 65/9.0 and a lactate level of 5mmol/L, but after 12 hours on fluids these numbers drop to 50/6.0 and 1.8 mmol/L, respectively, then that patient’s hydration status has significantly improved and the fluid rate should be adjusted accordingly. It is inevitable that potassium levels will decrease even in a healthy animal on fluids, but this is especially true in patients with disease states such as diabetic ketoacidosis or chronic kidney disease. Be sure to recheck electrolytes every 6 to 12 hours and add potassium as indicated.

Part 3: The approach to the critical patient and the role of the endothelial glycocalyx

Administering fluids to an overall healthy patient, such as one undergoing ovariohysterectomy or a dental procedure, differs tremendously from administering fluids to an ill patient. In addition to dealing with replacing volume deficits and treating shock, these patients have underlying conditions that often set off a systemic inflammatory cascade and predispose them to complications from fluid therapy. Restoring homeostasis in these patients is a challenge, and their specific needs can change by the hour or even the minute.

Rapid assessment of a critical patient’s perfusion parameters upon their arrival at the clinic is imperative to determine whether clinical signs of hypovolemia are present, what interventions are necessary, and to monitor the patient’s response to treatment. Hypovolemic patients will exhibit signs of hypoperfusion, including tachycardia (progressing to bradycardia in later stages of shock, and bradycardia is more common in cats), hypothermia, poor pulse quality, changes in mucous membrane color (pallor, gray/muddy), hypotension, and dull mentation. It is important to rule out cardiogenic shock as a cause of hypoperfusion, because fluid administration to patients in heart failure will worsen their disease state. If there is the presence of a heart murmur or gallop rhythm, dyspnea, abnormal lung sounds, or jugular distension, thoracic radiographs should be performed prior to making the decision as to whether fluid therapy is necessary. Any patient exhibiting signs of hypoperfusion should be provided flow-by oxygen immediately upon arrival.

If cardiogenic shock is ruled out, fluid resuscitation can be initiated while additional diagnostics are being performed. The shock volume in dogs is ~90 mL/kg, and in cats ~60 mL/kg.

 The recommendation is to administer a quarter of the shock volume (ie, approximately 20-25 mL/kg in dogs, 10-12 mL/kg in cats) over 20 minutes and reassess the patient’s perfusion parameters upon completion of the bolus.

In most cases, more information will be available after 20 minutes on completion of point-of-care ultrasound and blood work. At this point, you can determine whether additional boluses or other treatments, such as blood products, are necessary.

If you have determined that a patient is neither interstitially dehydrated nor hypernatremic, but still exhibiting signs of hypovolemia, it is reasonable at this point to administer a dose of HSS. HSS can be especially helpful in patients showing signs of acute hemorrhage (ie, trauma, hemoabdomen), because volume-restricted resuscitation is advocated to prevent dislodgement of any blood clots and potentially worsened hemorrhage. In many cases, administering a single 20 mL/kg crystalloid bolus along with 4 to 5 mL/kg of HSS will help maintain a systolic blood pressure between 60 and 90 mmHg (permissive hypotension) until blood products can be administered and the patient can proceed to surgery. HSS should also be considered as part of a low-volume resuscitation protocol in patients with head trauma.

If a patient is determined to be septic, crystalloid boluses at 10 to 20 mL/kg can be administered while hemodynamic variables are being monitored. If half of the shock dose has been administered and there is still significant hypotension, early vasopressor therapy should be considered.

These guidelines are based on multiple human studies, because there are no currently available guidelines regarding the use of IV fluids in animals with septic shock. Again, avoidance of the use of synthetic colloids in septic patients is important to prevent AEs associated with such products.

In the resuscitative phase of fluid therapy, frequent monitoring and reevaluation of perfusion parameters is important to determine the response to therapy and avoid fluid overload.

 In addition to the physical examination parameters listed above, other end points that can be used to evaluate perfusion more objectively include lactate, base deficit, and oxygen-transport variables. In human medicine, multiple studies have shown that reliance on traditional end points of resuscitation alone are insufficient in evaluating ongoing tissue hypoxia. Methods such as gastric tonometry, which specifically evaluate the perfusion of regional tissue beds, are also helpful in evaluating hypoxia, but many of these methods are not readily available in most veterinary settings. In critically ill patients, it is important to not only monitor traditional end points including blood pressure, heart rate, body temperature, capillary refill time, and urine output, but to also recheck values such as lactate, base deficit, blood gas analysis, and pulse oximetry with relative frequency, until these parameters begin to normalize.

Targeted end points of resuscitation in patients with shock include the following: systolic blood pressure, 80 to 100 mmHg; mean arterial pressure, 60 to 80 mmHg; base deficit –2 to 2 mEq/L; lactate 1 plus or minus 0.5 mmol/L; SvO2 greater than 70%; and pH greater than 7.32.

What is the endothelial glycocalyx and why is it important?

The endothelial glycocalyx has garnered much attention in recent years, and for good reason. The endothelial glycocalyx is a gel-like matrix that lines all vascular endothelial surfaces. It is composed of glycosaminoglycans, proteoglycans, and glycoproteins. It is a dynamic structure that has many functions, including hemostasis, inhibition of microthrombosis, regulation of adhesion and migration of leukocytes through endothelial cells, regulation of vascular tone and permeability, and regulation of fluid flux across endothelial cells. Many plasma proteins interact with the endothelial glycocalyx, including albumin, antithrombin III, and superoxide dismutase.

The results of damage to the endothelial glycocalyx can be catastrophic. Increased vascular permeability leads to capillary leakage and edema. Dysregulated cell-cell interactions lead to a proinflammatory and hypercoagulable state. Normal vascular reactivity and vessel tone are compromised. Shedding of the endothelial glycocalyx layer plays a prominent role in the pathophysiology of various critical illnesses, and care should be taken to reduce its damage.

There are many potential causes of damage to the endothelial glycocalyx, including sepsis and systemic inflammatory response syndrome, hemorrhage, hyperglycemia, ischemia-reperfusion injury, and hypervolemia. In the context of this article, it is important to understand that a hypervolemic state (fluid overload) leads to endothelial glycocalyx disruption. In addition, rapid administration of crystalloids or colloids can increase endothelial glycocalyx shedding.

 Therefore, it is important to always determine whether a fluid bolus is required in the first place, and why it is important to always be reevaluating a patient’s response to fluid therapy.

Many investigative studies have explored possible therapies to preserve or repair the endothelial glycocalyx. At this time, there does not appear to be one particular therapy that is strongly recommended, nor is there any available research specific to veterinary medicine. Treatments that have shown promise include early blood product administration, matrix metalloproteinase inhibitors, albumin, exogenous glycosaminoglycans, activated protein C, sulodexide, and heparin.

Because little is known about these treatments and many of them are not readily available, our best option as veterinary professionals is to make every effort to avoid further damage to the endothelial glycocalyx. A judicious, calculated approach to fluid therapy should be taken with every patient.

Cavanagh AA, Sullivan LA, and Hansen BD. Retrospective evaluation of fluid overload and relationship to outcome in critically ill dogs. J Vet Emerg Crit Care (San Antonio). 2016;26(4):578-586. doi:10.1111/vec.12477

2013 AAHA/AAFP Fluid Therapy Guidelines for Dogs and Cats. ImplementationToolkit. American Animal Hospital Association. 2013. Accessed July 12, 2021. 

https://Www.Aaha.Org/Globalassets/02-Guidelines/Fluid-Therapy/Fluidtherapy_Guidlines_Toolkit.Pdf

Londoño L. Fluid Therapy in Critical Care. Today’s Veterinary Practice. Accessed July 11, 2021. 

https://todaysveterinarypractice.com/fluid-therapy-in-critical-care/

Kim HY, Nam A, Song KH, Youn HY, Seo KW. Effect of 7.5% hypertonic saline solution on whole blood coagulation in healthy dogs using thromboelastography. J Vet Emerg Crit Care (San Antonio). 2020;30(4):442-448. doi:10.1111/vec.12959

DiBartola SP, Bateman S. Introduction to fluid therapy. In: DiBartola SP, ed. Fluid, Electrolyte, and Acid-Base Disorders in Small Animal Practice. Elsevier-Saunders; 2012:339.

Muir WW. Crystalloids or colloids? dvm360.com.! February 1, 2013. Accessed July 12, 2021. 

https://www.dvm360.com/view/crystalloids-or-colloids

Wurlod VA, Howard J, Francey T, Schweighauser A, Adamik KN. Comparison of the in vitro effects of saline, hypertonic hydroxyethyl starch, hypertonic saline, and two forms of hydroxyethyl starch on whole blood coagulation and platelet function in dogs. J Vet Emerg Crit Care (San Antonio). 2015;25(4):474-487. doi:10.1111/vec.12320

Kundra P, Goswami S. Endothelial glycocalyx: Role in body fluid homeostasis and fluid management. Indian J Anaesth. 2019;63(1):6-14. doi:10.4103/ija.IJA_751_18

Cazzolli D, Prittie J. The crystalloid‐colloid debate: consequences of resuscitation fluid selection in veterinary critical care. J Vet Emerg Crit Care (San Antonio). 2015;25(1):6-19. doi:10.1111/vec.12281

Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016. Crit Care Med. 2017;45(3):486-552. doi:10.1097/CCM.0000000000002255

Craft EM, Powell LL. The use of canine-speciﬁc albumin in dogs with septic peritonitis. J Vet Emerg Crit Care (San Antonio). 2012;22(6):631-639. doi:10.1111/j.1476-4431.2012.00819.x

Lee JA, Powell L. Fluid therapy in real-life practice: all you need to know!June 25, 2014. Accessed May 7, 2020. https://vetgirlontherun.com/wp-content/uploads/2014/06/FluidTherVG625141.pdf

Lat, I., Coopersmith, C.M., De Backer, D. et al. The surviving sepsis campaign: fluid resuscitation and vasopressor therapy research priorities in adult patients. ICMx 9, 10 (2021). 

https://doi.org/10.1186/s40635-021-00369-9

Prittie J. Optimal endpoints of resuscitation and early goal‐directed therapy. J Vet Emerg Crit Care. 2006;16(4):329-339. doi:10.1111/j.1476-4431.2006.00160.x

Gaudette S, Hughes D, Boller M. The endothelial glycocalyx: structure and function in health and critical illness. J Vet Emerg Crit Care (San Antonio). 2020;30(2):117-134. doi:10.1111/vec.12925

Knowing how to approach critical patients is key.