Audit of intravenous fluid prescribing and biochemical monitoring in children undergoing appendicectomy. Dr Rosie Snaith Dr 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 1Fluid boluses; 0.9% NaCl, 20ml.kg -1 2Check plasma electrolytes before commencing IV fluid 3Weigh child before commencing fluid and daily thereafter. 4Volumes accurately calculated (H and S) 5Recheck plasma electrolytes every 24 hours 6If [Na] < 130mmol.l -1 recheck within 4-6 hours

Recommendations cont. 8Maintenance fluid [0.45% sodium chloride +5% dextrose] 90.18% NaCl + 5% dextrose should not be administered. 10Ongoing losses; isotonic fluids such as 0.9% NaCl. 11Fluid balance charts accurately documented 13In 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 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 ).

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

Fluid boluses 10-20mls.kg -1 PPS =4.5% human albumin solution.

MANAGEMENT DURING SURGERY

Fluid boluses 5-20 mls.kg -1

MANAGEMENT AFTER SURGERY

Fluid boluses Volumes 5-20mls.kg -1

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?