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Audit of intravenous fluid prescribing and biochemical
monitoring in children undergoing appendicectomy.
Dr Rosie SnaithDr J. Peutrell.
June 2007
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Introduction
4 reported deaths in UK since 2000 Hyponatraemia Intravenous fluid administration. National Patient Safety Agency
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Aim
Determine if existing practice followed guidelines.
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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
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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.
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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
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Methods
Retrospective review 100 records Appendicectomy. Structured questionnaire.
Before surgery During surgery After surgery
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Questionnaire
Fluid IV boluses Fluid for maintenance therapy Fluid volumes administered Nasogastric loss replacement Weights
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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
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RESULTS
Ages 2-14 (median 10, IQR 8-11.25).
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MANAGEMENT BEFORE SURGERY
97 had plasma electrolytes on admission
97 commenced on fluids on admission.
21 had [Na] < 135mmol.l-1
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• 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
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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
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MANAGEMENT DURING SURGERY
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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
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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
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MANAGEMENT AFTER SURGERY
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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
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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
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BIOCHEMICAL MONITORING
On admission: 97 patients No monitoring: 3 patients Only once: 54 patients. Daily monitoring: Nil
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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
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Repeat monitoring
[Na] < 130mmol.l-1
< 6 hours: 1 patient
[Na] < 135mmol.l-1
< 24 hours: 17 occasions
Not repeated 10 patients
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Maintenance fluid and [Na]<135mmol.l-1.
Admission
21/21 patients prescribed hypotonic solutions
[0.45% NaCl + 5% dextrose] +/- KCl
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Maintenance fluid and [Na]<135mmol.l-1.
During hospital stay
26/27 prescribed hypotonic fluid
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Nasogastric losses
Nasogastric losses significant; 3 pts.
Replacement; 0.9% NaCl
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Body Weight
100 patients weighed on admission.
No daily recordings.
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Charts
99% fluid balance charts. 98% intravenous fluid charts. 90% anaesthetic charts.
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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.
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Thankyou. Any questions?