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Elaine Hamilton
Practice Development Nurse
IV Fluid Management
Why Change?
• National Confidential Enquiry into Perioperative deaths (1999) highlighted:
– Significant numbers of patients in hospital were dying as a result of too MUCH or too LITTLE fluid
– rarely reported as a patient harm
– 1 in 5 patients on IV fluids and electrolytes suffer complications or morbidity due to inappropriate IV Fluid prescription and administration
• Provides clear guidance for prescribers
– Principles of fluid prescribing
– Changes within the body that can affect fluid balance when a patient is unwell
– Indications for IV fluid therapy
– Reasons for choosing particular fluids
– Assessment of fluid balance
• Programme launched Feb 2018
• Based on principles within the NICE Guideline
• Purpose of the programme is to improve clinical care and reduce artificial variation in how we manage patients who require intravenous fluid therapy
NHS Scotland IV Fluid Improvement Programme
Prescribing the wrong type or amount of fluid can do serious harm
Assessment of fluid requirements needs care and attention, with adjustment for the individual patient
Safe prescribing and administration of IV fluids is just as important as safe prescribing and administration of oral and IV medicines.
Patient Harm
Too much fluid(Over replacement)
Too little fluid (Under treatment)
Fluid overload Acute Kidney Injury
Pulmonary oedema Volume Depletion
Peripheral oedema Shock
So what is normal?
Component Requirement What does that look like for ahealthy 80kg adult per day
Water 30ml / kg / day
For the elderly or frail, those with renal or cardiac impairment or malnutrition 20-25ml / kg / day
2,400mls
Sodium 1mmol / kg / day 80mmols
Potassium 1mmol / kg / day 80mmols
Chloride 1mmol / kg / day 80mmols
Glucose 50-100g / day 50g
Patient weight = 75 kg Fluid requirement for 3 days was 6.75 L(=30ml / kg / 24hrs)In 72 hours patient received:0.9% Sodium Chloride 6100 mlHartmanns 4000 ml5% Glucose 1000 m l Actual volume received = 11 LSodium, Chloride and Potassium requirements: 3 days x 75 = 225 mmol of each(= 1mmol / kg / 24hrs)Actually 1463 mmol SodiumReceived 1383 mmol Chloride
27.5 mmol Potassium Chloride
Over the 3 days the patient received
- 4 litres of water more than was required
- 6 times the amount of Sodium and Chloride required
- Only 12% of the Potassium requirement
All have the potential to cause patient harm
Key changes in Fluid Management
NHSGGC Clinical Guideline for Intravenous Fluid & Electrolyte Prescription in Adults
New Adult IV Fluid Prescription Chart
Maintenance fluids based on patient’s weight & prescribed in ml/hr
Types of preferred IV fluids – New fluids being introduced
Volume of infusion bags – Change from 500ml to 1L bags
New Fluid Balance Monitoring Chart including subtotals and stop & check prompt
Assessment for IV Fluids
It is vital that patient receive
**The right amount of the right fluid at the right time**
Questions prescribers need to answer during assessment before prescribing IV fluids:
1. Is the patient euvolaemic, hypovolaemic or hypervolaemic?
2. Does the patient need IV fluid? If so why?
3. How much fluid do they need?
4. What type(s) of fluid do they need?
Pilot IV Prescription chart
Pilot IV Prescription chart
Maintenance Fluids
• For patients who cannot meet their daily fluid and electrolyte needs through oral or enteral routes
• 0.18% Sodium Chloride + 4% Glucose + 0.3% Potassium Chloride (this bag contains 40mmols of Potassium)
• 1000ml bags
Some IV medicines must be given by infusion rather than bolus, for example:
•Vancomycin 1g in 250ml NaCl 0.9% twice a day =
77mmol Na and Cl per day and 500ml fluid
•Metronidazole 500mg in 100ml NaCl 0.9% 3 x day =
39mmol Na and Cl and 300ml fluid
•Benzylpenicillin 1.2g in 100ml NaCl 0.9% 4 x day =
75mmol Na and Cl and 400ml fluid
Fluid and electrolytes from IV medicines
Losses
• Vomiting
• diarrhoea
• NG suction
• Drains
• Bile leaks
• High stoma output
• Blood loss etc
Source: Copyright – National Clinical Guideline Centre
‘Intravenous fluid therapy in adults in hospital’, NICE clinical guideline 174 (December 2013) © National Institute for Health and Care Excellence 2013.
All rights reserved.
Review/Reassess
All patients should be reassessed daily until stable
• Are fluids still required?
• What is the maintenance goal for today?
• Document on the fluid prescription chart – STOP, REVIEW, or CONTINUE after this bag.
Pilot Fluid Balance Chart
Pumps
Current Position
• Testing guideline and prescription chart in 4 wards
• Testing education materials as part of the pilot
• Approval of guideline and chart
• Exploring electronic solutions
• Developing a communication strategy
• Staged approach to implementation
