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?