Audit of intravenous fluid prescribing and biochemical
monitoring in children undergoing appendicectomy.
Dr Rosie SnaithDr J. Peutrell.
June 2007
Introduction
4 reported deaths in UK since 2000 Hyponatraemia Intravenous fluid administration. National Patient Safety Agency
Aim
Determine if existing practice followed guidelines.
Recommendations
1 Fluid boluses; 0.9% NaCl, 20ml.kg-1
2 Check plasma electrolytes before commencing IV fluid
3 Weigh child before commencing fluid and daily thereafter.
4 Volumes accurately calculated (H and S)
5 Recheck plasma electrolytes every 24 hours
6 If [Na] < 130mmol.l-1 recheck within 4-6 hours
Recommendations cont.
8 Maintenance fluid [0.45% sodium chloride +5% dextrose]
9 0.18% NaCl + 5% dextrose should not be administered.
10 Ongoing losses; isotonic fluids such as 0.9% NaCl.
11 Fluid balance charts accurately documented
13 In some circumstances only isotonic fluid should be administered.
Special circumstances
Isotonic fluid should be used; 1. Peri- and postoperative children, 2. [Na] lower end of normal or
<135mmol.l-1 3. CNS infections, 4. Head injury, 5. Bronchiolitis, 6. Excessive gastrointestinal losses
Methods
Retrospective review 100 records Appendicectomy. Structured questionnaire.
Before surgery During surgery After surgery
Questionnaire
Fluid IV boluses Fluid for maintenance therapy Fluid volumes administered Nasogastric loss replacement Weights
Electrolytes before maintenance fluid
Daily electrolytes If Na < 130mmol.l-1 electrolytes < 6
hrs Isotonic fluid peri and post op. Isotonic fluid if Na < 135mmol.l-1
RESULTS
Ages 2-14 (median 10, IQR 8-11.25).
MANAGEMENT BEFORE SURGERY
97 had plasma electrolytes on admission
97 commenced on fluids on admission.
21 had [Na] < 135mmol.l-1
• Fluid volumes; 4,2,1,ml.kg.hr-1
Maintenance fluid prescribed before theatre
0
20
40
60
80
100
Fluid type
Pa
tie
nt
nu
mb
er
(n=
10
0)
Series1 94 3 2 1
0.45% NaCl + 5% dextrose +/- 20mmol/L KCl
Nil Not documented Mixture
Fluid boluses
• 10-20mls.kg-1
• PPS =4.5% human albumin solution.
Fluid type for boluses
0
20
40
60
Fluid type
Bo
lus
nu
mb
er (
n=
66)
Series1 54 12
0.9% NaCl PPS
MANAGEMENT DURING SURGERY
Maintenance fluid prescribed during surgery
0
20
40
60
Fluid Type
Pat
ien
t n
um
ber
(n
=100
)
Series1 51 28 10 6 3 1 1
Hartmann's solution
0.45% NaCl + 5% dextrose +/- 20mmol/L KCl
Not documented
Mixture PPS 0.9% NaCl 10% dextrose
Fluid boluses
• 5-20 mls.kg-1
Fluid type for fluid boluses
0
5
10
15
20
25
Fluid type
Bo
lus
nu
mb
er
(n=
39
)
Series1 21 19 2 1 1
Hartmann's solution
PPS FFP NaCl0.45% NaCl
+ 5% dex
MANAGEMENT AFTER SURGERY
Maintenance fluid prescribed after surgery
0
20
40
60
80
100
Fluid type
Pat
ien
t n
um
ber
(n
=100
)
Series1 92 4 3 1
0.45% NaCl + 5% dextrose +/- 20mmol/L
KClMixture Hartmann's mix Not documented
Fluid boluses
• Volumes 5-20mls.kg-1
Fluid type for boluses
0
5
10
15
Fluid type
Bo
lus n
um
ber
(n=
24)
Series1 13 10 1
0.9%NaCl PPS Hartmann's
BIOCHEMICAL MONITORING
On admission: 97 patients No monitoring: 3 patients Only once: 54 patients. Daily monitoring: Nil
Biochemical results
[Na] <135 mmol.l-1 admission: 21 pts
[Na] <135 mmol.l-1 subseqent: 6 pts
[Na] <130mmol.l-1: 3 pts
Total samples [Na] <135mmol.l-1: 46
Repeat monitoring
[Na] < 130mmol.l-1
< 6 hours: 1 patient
[Na] < 135mmol.l-1
< 24 hours: 17 occasions
Not repeated 10 patients
Maintenance fluid and [Na]<135mmol.l-1.
Admission
21/21 patients prescribed hypotonic solutions
[0.45% NaCl + 5% dextrose] +/- KCl
Maintenance fluid and [Na]<135mmol.l-1.
During hospital stay
26/27 prescribed hypotonic fluid
Nasogastric losses
Nasogastric losses significant; 3 pts.
Replacement; 0.9% NaCl
Body Weight
100 patients weighed on admission.
No daily recordings.
Charts
99% fluid balance charts. 98% intravenous fluid charts. 90% anaesthetic charts.
Conclusions
[Na] <135mmol.l-1 in 27 patients. Maintenance fluid hypotonic. Isotonic fluid not prescribed when
[Na] low or peri/postoperatively. Fluid not individualised. Biochemical monitoring infrequent. Not meeting NPSA
recommendations.
Thankyou. Any questions?