EP.TU.364Intravenous fluid prescribing – common pitfalls and suggestions for improvement

Aim Intravenous fluids are no doubt most prescribed treatments in surgical practice. It is also an area where junior doctors’ performance is commonly found deficient. There appeared to be a gap in general knowledge of fluid and electrolyte management. Our audit aims to assess the competency of surgical juniors in fluid prescribing as compared to recommendations set out by GIFTASUP 2011. FY1s have also been asked to complete a survey on fluid and electrolyte management. Method We included all adult surgical inpatients (28) admitted over one week to our DGH who were started on IV fluids for maintenance only. We retrospectively audited their prescription charts and medical notes. FY1's in the department have been also asked to fill out a short survey testing their knowledge on fluid and electrolyte requirements. Following this, we held a tutorial on fluid management of surgical inpatients for FY1's. We also made fluid management algorithm available in SAU for reference. Results Data was tabulated and outcomes compared with CG174 guidance. Cycle 1 showed poor compliance with only about 50% patients being prescribed appropriate intravenous fluid volumes. FY1’s completing the survey scored 54% on average. Often previous fluid prescription was copied. Cycle 2 showed some improvement in appropriate volumes and choice of maintenance fluids prescribed, and better survey score of 64%. There was also improvement on the understanding of daily fluid and electrolyte requirement from the FY1 cohort. Conclusions We suggest implementing varied educational approach to improve on fluid prescribing and patient outcomes in hospital.

606 AUDIT: IV Fluid Prescribing in Surgical Patients

Aim A recent change to electronic fluid prescribing has enabled us to evaluate our adherence to recommendations. NICE clinical guideline 174 states that patients should receive 25-30ml/kg/day water and 1mmol/kg/day of sodium, potassium, and chloride with regards to maintenance fluid therapy. We retrospectively audited our practice in surgical patients. Method Patients were selected from two surgical inpatient wards in a district general hospital utilising random sampling over a one-month period. Prescribed intravenous fluid (IV) therapy over a 24-hour period was collected; in addition to weight, presence of an acute kidney injury (AKI) and indication for IV replacement (maintenance versus resuscitation). Results 50 patients were identified during the period. All of them were emergency presentations. Maintenance fluids were prescribed for 76% of patients. No patients had an AKI at time of data collection. The mean weight was 75kg. Overall, patients received a mean fluid volume of 2.3L/day. The mean concentration of electrolytes administered over a 24-hour period were: Sodium 297mmol, Potassium 13mmol, Chloride 237mmol. When adjusting for patient weight, this resulted in a net administration of: Sodium +221mmol, Potassium -62mmol, Chloride +162mmol. Conclusions Three quarters of surgical patients were administered maintenance fluids. The electrolyte contents of these fluids were inadequate. Patients received 295% excess Sodium, 216% excess Chloride, and 82% less than the recommended daily requirement of Potassium. We aim to introduce a protocol for maintenance fluid prescribing, in addition to teaching sessions, that would allow for adherence to guidelines and improve patient care.

Hyponatraemia despite isotonic maintenance fluid therapy: a time series intervention study

ObjectiveTo examine the prevalence of dysnatraemias among children admitted for paediatric surgery before and after a change from hypotonic to isotonic intravenous maintenance fluid therapy.DesignRetrospective consecutive time series intervention study.SettingPaediatric surgery ward at the Children’s Hospital in Lund, during a 7-year period, 2010–2017.PatientsAll children with a blood sodium concentration measurement during the study period were included. Hypotonic maintenance fluid (40 mmol/L NaCl and 20 mmol/L KCl) was used during the first 3 years of the study (646 patients), and isotonic solution (140 mmol/L NaCl and 20 mmol/L KCl) was used during the following period (807 patients).Main outcome measuresPrimary outcomes were sodium concentration and occurrence of hyponatraemia (<135 mmol/L) or hypernatraemia (>145 mmol/L).ResultsOverall, the change from hypotonic to isotonic intravenous maintenance fluid therapy was associated with a decreased prevalence of hyponatraemia from 29% to 22% (adjusted OR 0.65 (0.51–0.82)) without a significantly increased odds for hypernatraemia (from 3.4% to 4.3%, adjusted OR 1.2 (0.71–2.1)). Hyponatraemia <130 mmol/L decreased from 6.2% to 2.6%, and hyponatraemia <125 mmol/L decreased from 2.0% to 0.5%.ConclusionsRoutine use of intravenous isotonic maintenance fluids was associated with lower prevalence of hyponatraemia, although hyponatraemia still occurred in over 20% of patients. We propose that the composition and the volume of administered fluid need to be addressed.