1. Problems with Solutions
GUIDANCE FOR IV FLUID AND ELECTROLYTE PRESCRIBING IN FIFE
Fluid Prescription Working Group May 2012

2. WHY HAVE WE PRODUCED THIS GUIDANCE?
Fluid prescribing is done poorly.
Certain problems can arise:

3. Too wet

4. Too dry

5. LACK OF EDUCATION AND ATTENTION TO DETAIL

6. IT’S COMPLICATED!
Please don’t write up fluids on patients you know nothing about without looking at various parameters (to be explained below)

7. The background National reports Recent national guidelines
National meetings
Doctors’ level of knowledge and application
Observation of practice
Local audits

8. Abnormal Saline
Is there a problem nationally?

9. 1999
Patients are dying as a result of infusion of too much or too little fluid by inexperienced staff.
New doctors have inadequate knowledge and sub-optimal prescribing skills
Fluid prescription must be given the same status as drug prescription.

10. Walsh et al Ann Roy Coll Surg Engl 2005
Poor fluid management contributed to around half of the deaths
SASM Report 2008
Errors in fluid prescription are common in hospital practice and are dangerous
Shaifee et al QJM 2003
17% of postoperative patients develop morbidity directly related to fluid prescription
Walsh et al Ann Roy Coll Surg Engl 2005
Has anything changed since 1999?

11. Fluid Prescribing Left to the most junior member of the team
Wide variability in prescribing practices
About 26% prescribed > 2L 0.9% saline/day
Lobo et al Clin Nutr 2001

12. Fife 2012
Brief survey of juniors in HDU and anaesthesia
Poor knowledge of maintenance requirements
Poor knowledge of Na/K requirements
No system for calculating peri-operative fluid requirements
Fluid therapy is often poorly taught, poorly understood and poorly done

13. Some examples 75 year-old lady Post Hartmanns, 55kg
Not well 5 days post-op: SOB, oedematous
On TPN AND IV fluids : >3L/day
Na 130
Lungs wet
Ileus
Gross peripheral oedema
Needs fluid restriction; stop IV fluids
Gentle diuresis

14. Overload in Orthopaedics
80 year-old man: Mild angina and mild aortic stenosis, independent, N U&Es, 60kg
Op delayed for 6 days, fasted on and off for 6 days. Minimal food intake.
16.5 litres IV fluid in 6 days (requirement approx 1800ml/day = 10.8l), Na day 5 =128
Day 7 – surgery – still fasting, more IV fluid,
D 8 Na 123 – cardiac failure, pulmonary oedema, angina. Frusemide++
D 9 creatinine 300, urea 10. All iatrogenic
PREVENT!

15. Excess loss/ Inadequate provision
80 yrs, post-Hartmanns – developed high NG losses, 4 litres/day for 1 week
Fluid balance on ward not properly addressed
Developed severe alkalosis on the ward:
pH 7.61 and severe dehydration, low Na/K
Admitted to ICU for two days for correction before he could go back to theatre: anastomotic leak discovered
Orthopaedics 80 yr old, 60kg with Alzheimer’s: #NOF 3 litres/5days (maintenance: 9 litres)

16. 4 Audits in Fife
Lots of patients not getting much fluid, especially in orthopaedics
Some got far too much, especially in surgery
Not enough potassium – all areas
Far too much sodium – all areas
BUT: Education improves practice

17. SHDU Results
2/3 of patients got too much sodium, in some cases excessively so (> 800mmol Na on one occasion)
On 1/3 of patient–days roughly (+/- 500ml) the right volume of fluid was given, on 1/3 too much, and on 1/3 too little
Fewer than 1/2 patients received enough potassium. Excess losses were generally not replaced

18. Anaesthetic audit: Results
Patients with higher intra-operative fluid volumes experienced more post-op complications as well as more PONV (chest infections, arrhythmias, ileus, low BP, confusion)
High volumes of Hartmanns are given peri-operatively and it is often used as a maintenance fluid post-op – it is not one

19. Lessons from physiology
What should we do?
Lessons from physiology

20. The right amount
of the right fluid
at the right time

21. Moderation FD Moore & GT Shires, Ann Surg 1967
The objective of medical care is restoration to normal physiology and normal function of organs, with a normal blood volume, functional body water and electrolytes. This can never be achieved by inundation.

22. In the distant past... Wounded/sick animal or person
No food or water may be available for hours until he drags himself to the waterhole
Retains fluid by oliguria and anti-diuresis, trying to maintain blood volume
Stress response to trauma mediated by Renin angiotensin aldosterone system (RAAS), ADH and catecholamines

23. Catabolic Response to Injury/Illness
Sodium and water retention (ADH, RAAS, catecholamines)
Capacity of kidneys to excrete water and Na is impaired
Increased potassium excretion (due to RAAS activity and protein catabolism)
Decreased urine output
Sicker patients have poor concentrating ability – poor excretion of Na and Cl load
Catabolic patients produce more urea which is excreted in preference to Na and Cl and this increases water retention

24. What do we often do? We give lots of fluid, lots of sodium chloride
Kidneys can’t excrete sodium load
Chloride causes renal vasoconstriction and exacerbates fluid retention and oedema
Leaky capillaries in sick patients exacerbate RAAS/ADH activity and oedema worsens
We don’t give much potassium
Potassium depletion reduces ability to excrete sodium
We don’t give many calories
Calories help the cells to maintain fluid homeostasis

25. Too wet

26. Salt & Water overload: Physiological Consequences
Decreased renal blood flow and GFR
Intra-mucosal acidosis
Prolongation of gastric emptying time
Ileus (+ low K+, opioids, poor mobility, pain)
Hyperchloraemic acidosis
Weight gain
Low serum sodium - ? More given
Cellular dysfunction

27. Salt & Water Overload: clinical
Peripheral oedema
Gastro-intestinal oedema: N & V
Impaired cardiac function: Pulmonary oedema/ARDS
CCF/arrhythmias
Confusion
Delayed mobilisation
Pressure sores
Increase in DVT

28. Too dry

29. Salt & Water Depletion
Reduced stroke volume – poor organ perfusion, hypotension, falls
Impaired renal perfusion - ARF
Increased viscosity of mucus
Reduced saliva - discomfort
Increased blood viscosity - clots

30. Problems with Solutions
PROBLEMS WITH SALINE

31. The Origins of 0.9% Saline
Not a physiological fluid – based on a mistake by a physiologist called Hamburger in 1830s
He thought concentration of salt in blood was 0.9% but it is nearer 0.6%
0.9% NaCl is not a maintenance fluid
It has certain specific uses

32. The Abuse of Normal Salt Solution George H. Evans, JAMA 1911
“One cannot fail to be impressed with the danger of the utter recklessness with which salt solution is frequently prescribed, particularly in the postoperative period…”
“…the disastrous role played by the salt solution is often lost in light of the serious conditions that call forth its use.”

33. The Times, 28 January 2000

34. Hartmanns solution/Ringer’s Lactate
Discovered independently by Hartmann and Ringer
‘Balanced’ solution i.e. More like the composition of plasma, has lactate as a buffer
Less Na and Cl load and the Na load is more effectively excreted with less fluid retention (there still is some), less acidosis and less effect on albumin and Hb than saline
It is a good REPLACEMENT fluid when a patient has lost body fluids

35. Evidence
Experiments have shown that in healthy volunteers, infusion of 2 litres of saline results, after 6 hours, in weight gain due to fluid retention, a drop in albumin and Hb, acidosis, poor uop and retention of sodium. 2 litres of Hartmanns is better than saline for all of these parameters, and dextrose is the best in terms of lack of fluid retention and uop.
This fluid retention is worse in sick patients.
Dextrose-containing maintenance fluids are best but ensure not too much is given – the right amount!

36. Post -op
Other studies have shown that patients having significant amounts of unnecessary fluid peri-operatively have more complications e.g. poor wound healing, chest infections, slow mobilisation, nausea and vomiting
The fluid given must be tailored to each patient’s situation.

37. There is a very narrow range for optimal fluid load

38. NHS Fife
Guidelines for intravenous fluid and electrolyte prescription in adults
Group: M.McDougall, S. Oglesby,
S. Bennett, A. Doyle, K. Buck, A. Sengupta,
L. Clark, J. Hadoke, A. Timmins,
K. Spurgeon, M. Clark, A. Rahman,
L. Reekie.
Based on GIFTASUP guidelines

39. Jeremy Powell-Tuck (chair), Peter Gosling,
British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients
GIFTASUP
Jeremy Powell-Tuck (chair), Peter Gosling,
Dileep N Lobo, Simon P Allison, Gordon L Carlson, Marcus Gore, Andrew J Lewington,
Rupert M Pearse, Monty G Mythen
BAPEN Medical, the Association for Clinical Biochemistry, the Association of Surgeons of Great Britain and Ireland, the Society of Academic and Research Surgery, the Renal Association and the Intensive Care Society.

40. 1. Balanced salt solutions e. g
1.Balanced salt solutions e.g. Ringer’s lactate/acetate or Hartmann’s solution should replace 0.9% saline when crystalloid resuscitation or replacement is indicated except in hypochloraemia 1b 2.Solutions such as 4%/0.18% dextrose/saline and 5% dextrose are important sources of free water for maintenance. Excessive amounts may cause hyponatraemia, especially in the elderly 1b

41. Recommendation 3
To meet maintenance requirements, patients should receive sodium mmol/day, potassium mmol/day in litres of water by the oral, enteral or parenteral route (or a combination of routes).
Additional amounts should be given to correct deficit or continuing losses. Careful monitoring should be undertaken using clinical examination, fluid balance charts and regular weighing, when possible.
Evidence level 5

42. Questions to ask before prescribing fluid
Does my patient need intravenous fluid?
Why does my patient need intravenous fluid?
How much and which fluid does he need?

43. Does he need fluid? May be drinking
May be on NG feed/TPN – both of these contain fluid which counts as maintenance
May be receiving many drug infusions e.g. antibiotics/paracetamol – can amount to 1+ litre/day
He may only need a bit of maintenance fluid
This calculation should be done for each patient

44. Why does he need fluid? Maintenance –water and electrolytes
To supply the daily needs –
(e.g. 4% dextrose/0.18%saline/KCl)
Replacement To replace ongoing losses
know the content of the fluid!
Resuscitation - e.g.colloid/blood
To correct an intravascular or extracellular volume deficit

45. MAINTENANCE
If you were on a desert
island, would you drink
from the sea or a stream?
0.9% saline is not
a maintenance fluid

46. Daily Requirements (GIFTASUP)
Water ml/kg (30)
Sodium approx 1 mmol/kg
Potassium approx 1 mmol/kg
Calories minimum 400 Calories (i.e. 100 g dextrose)
(calories help to deal with electrolytes normally)

47. Average Daily Requirements
70 kg man needs: ml H2O
70 mmol Na+
70 mmol K+
70 mmol Cl-
50kg man needs 1500 ml H2O
50 mmol Na+
50 mmol K+
50 mmol Cl-

48. Properties of Commonly Used Crystalloid Solutions
Electrolyte Content
(mmol/l)
Osmolality (mOsm/kg) pH
0.9% NaCl
Na+ 154
Cl- 154
308
5.0
Dextrose (4%)-Saline (0.18%)
Na+ 31
Cl- 31
286
4.5
5% Dextrose
Nil
280
4.0
Hartmann’s solution
Na+ 131 K Ca Cl
HCO3- 29
276
6.5

49. MAINTENANCE
Prescribe maintenance if not drinking >6hrs
4%/0.18% dextrose/saline with 20mmol potassium in 500ml, or 40mmol in 1 litre (1 litre is cheaper). Or no potassium
Prescribe in ml/hr (see table) via a pump.
The correct volume of this by weight per day for maintenance will provide roughly the correct amount of sodium and potassium for each patient. Maximum 100ml/hr to avoid hyponatraemia. Do not prescribe x hourly

50. PUMPS
At present there are just about enough but distribution is a big problem
We are hoping to get more and distribute them better in the hospital
Each ward will have their own so it is important to keep hold of them and get them back if they leave
If a patient is on dex/saline they really should have a pump to ensure the correct rate is given.
If a patient is on fluids of any kind for >6 hours they should have a pump

51. Potassium
A normal serum potassium is not an indication that the patient does not need potassium – it just means that their stores haven’t run out yet.
A low potassium means that losses are high and body stores very low.
A high potassium may be drug related but commonly is due to acute renal failure – monitor U&Es and do not give extra K.
Remember that TPN, NG feed and food contain K

52. Sodium
We all need some. However most drugs contain sodium so we don’t need to give a lot in fluids unless the patient is losing it.
Causes of a low Na – too much fluid (commonest cause in hospital!) – fluid restrict
SIADH inappropriate antidiuretic hormone secretion– pneumonia, brain pathology
High Na loss – usually upper GI losses – tend to be obvious

53. Fluid overload Recognise clinical signs May need fluid restriction
Careful fluid balance and monitoring
Gentle diuresis – beware of precipitating ARF in a patient whose kidneys may not be working efficiently

54. REPLACEMENT
Losses should be accounted for with replacement fluid: balanced solution: Hartmanns (Plasma Lyte 148 – may become available, has Mg, no Ca, acetate not lactate)
Work out how much patient is losing and replace this with Hartmanns – better to calculate retrospectively and replace.
Fluid prescriptions for losses must be reviewed regularly and updated.

55. LOSSES
Upper GI loss: stomach, small bowel ileostomy/fistula/bile leak: high Na and Cl content – may become hypochloraemic and alkalotic – appropriate to use 0.9%NaCl
Lower GI loss: diarrhoea - lose lots of water and potassium: Hartmanns is appropriate to replace + extra potassium (guide in booklet)

56. How much fluid does he need?
Weight for maintenance 30ml/kg/24hrs
History, fasting, losses, sepsis, fluid balance charts
Clinical status, current losses, fluid intake, urine output
Electrolytes, Hb (may be raised in dehydration)

57. Exclusions Paediatric patients: consult paediatrician
Diabetic patients: follow diabetic guidelines
Head injury patients: avoid dextrose
Renal failure patients: consult senior doctor
Obstetrics: consult obstetric team in complex patients

58. Resuscitation Fluid
For severe dehydration, sepsis or blood causing circulatory hypovolaemia and hypotension
Use Hartmanns or colloid, blood/O Negative in emergencies
May need critical care referral for inotropic support/ invasive monitoring
Criteria for Critical Care Referral – on guidance
Algorithm for fluid challenges
Elective patients
Will get pre op fluids orally
Should get clear fluids up until 2 hours pre op Cochrane meta analysis
Emergency patients
May need iv maintenance and resuscitative fluids
Give appropiate resuscitation fluid
Carbohydrate drinks help to reduce thirst, anxiety, PONV
Bowel prep
Only when required
Patient should get iv fluid if NBM

59. Fluid challenge 250ml colloid or Hartmanns over 2-5 mins
Don’t go away!
Looking for improved UOP, improvement in perfusion/BP/HR
Can be repeated – if patient still looks hypovolaemic after 2 litres senior help is required – may need inotropes and ICU
Very few patients will go into LVF with 250ml fluid (less than a can of coke!)

60. Colloids
Gelofusine – currently in 0.9%NaCl but will soon be in a balanced solution
Albumin 4.5%
Starch – for specialised use in theatre/ICU
Some controversy about which is best
For your purposes don’t worry about this!

61. Summary Remember the three questions
Doctors should take time and consult senior if unsure
Patients on IV fluids need regular U&Es
Patients should be allowed food and drink as soon as possible

62. The right amount
of the right fluid
at the right time