A Little more salt with that order?

IV Fluids in PaediatricsRachael Worthington

The Children’s Hospital at Westmead

Background

• The danger of intravenous hypotonic saline administration, to acutely ill or post-operative children has been well documented over the past decade.

• Children’s Hospitals Australasia (CHA) Medication safety SIG Intravenous Fluids Working Party, in line with other safety organisations, released intravenous fluid guidelines which addresses this.

• Local intravenous fluid types for use in children and adolescents across a range of settings, including maintenance fluids, the perioperative period, dehydration and resuscitation, were reviewed. Moritz ML and Ayuz JC Pediatr nephrol 2005

Armon et al Arch Dis Child 2008

Questions raised

• Is there really harm from hypotonic saline?

• Is maintenance fluid volume too much?

• How should we be monitoring?

• Sodium Chloride 0.45% vs 0.9% vs balanced salt solution

Na+

Hatherill Arch Dis Child 2004Coulthard MG Arch Dis child 2008

Local incident data - 2011

• Graph showing IV fluids up there over last 4 years

Ongoing trend

CHW Incident data

8%

28%

8%4%

48%

4%

IV Fluid Prescribing Incidents 2011N=25

DocumentationNot prescribedPolicy and procedureUnclear/ambiguousWrong IV fluidsWrong patient ID

38%

1%

2%1%1%

2%4%12%

11%

13%

14%

IV Fluid Administration Incidents 2011N=91

ExtravasationNo orderCeased incorrectlyExpired stockIV incompatibilityLine issuesOmissionPolicy and procedureWrong order administeredWrong IV FluidsWrong rate

IV fluid management

policy

IV fluid order form

Educational materials• JMO lunchtime

teaching• PrInt students• Undergraduates• Nursing orientation

Method: Audits• IV fluid data was collected, from current fluid order charts, patient notes, and the

clinical documentation system (PowerchartTM) on a single day in February 2010 (pre-change) and in October 2012 (post change) from every hospital ward, with the exception of the Neonatal Nursery.

• Data collected included demographic patient data (diagnosis, co-morbidities and factors associated with non osmotic ADH secretion), IV fluids, additives and rate prescribed, fluid balance and serum electrolytes.

• The quality of prescribing of IV fluids was also documented.

• Data was analysed for type of fluid used (maintenance and bolus), appropriateness (met patient requirements), presence of hypo or hypernatraemia (and any action taken) and quality of prescribing.

• Hyponatraemia was defined as mild (Sodium <135mmol/L) or moderate/severe (Sodium <130mmol/L)

• Hypernatraemia was defined as mild (Sodium > 145mmol/L) and moderate/severe (Sodium >150mmol/L)

DemographicsMean (Range) Audit 1 n=95 Audit 2 n=104

Age 6.54 (9 days-18 years) 6.44 (7 days-18 years)

Male 58 58

Weight (Kg) 25.75 (3.5-69.8) 23.53 (2.83-87)

Medical/surgical 59/36 53/51

Duration of IV Fluids (dys) 8.92 (<1 – 70) 10.3 (<1-80)

Sodium Range (mmol/L) 127-144 121-154

Number fluid boluses 37 29

Audit 1 (2010) Results

Audit 1 and 2 results comparedAudit 1 n=98 Audit 2 N=104

Fluids met requirements 100% 100%

Hypernatraemia? 0% 1%

Hyponatraemia? 32% 34%

Sodium Chloride 0.225% prescribed

0% 0%

Sodium Chloride 0.9% used as bolus fluid (crys)

97% 100%

Daily weights as per protocol?

38% 35%

Electrolytes monitored as per protocol?

27% 32%

Quality of prescribing: orders clear/complete?

No-84% No-90%

Discussion

• No change in hyponatraemia or hypernatraemia observed – but fluid types used only marginally changed.

• Use of sodium chloride 0.9% plus 5% glucose as maintenance is slowly increasing (PICU).

• Documentation needs to be tightened across the board. • Regular cycle of audit. • Educational input to date (JMO lunches, PrInt students,

undergraduates, nursing orientation) – enough?

Multi faceted approach over 4 years

• Clinician engagement• Multi D communication• Interactive education• Timely feedback

In summary

• IV fluids still feature in the top 5 Medication/IV fluid incident reports every month.

• Statewide NSW paediatric IV fluid guidelines have been developed based on CHA recommendations.

• Maintaining/sustaining policy into practice – ‘active’ implementation, ongoing education, ‘living’ policy with timely review, safety culture, audit and feedback, changing educational strategy.

• Change to sodium chloride 0.9% or balanced salt solution in the near future

• One size does not fit all.

Questions