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1. Audit of intravenous fluid prescribing and biochemical monitoring in children undergoing appendicectomy. Dr Rosie Snaith
Dr J. Peutrell.
June 2007
2. Introduction 4 reported deaths in UK since 2000
Hyponatraemia
Intravenous fluid administration.
National Patient Safety Agency
3. Aim Determine if existing practice followed guidelines.
4. Recommendations
5. Recommendations cont.
6. Special circumstances Isotonic fluid should be used;
Peri- and postoperative children,
[Na] lower end of normal or <135mmol.l-1
CNS infections,
Head injury,
Bronchiolitis,
Excessive gastrointestinal losses
7. Methods Retrospective review 100 records
Appendicectomy.
Structured questionnaire.
Before surgery
During surgery
After surgery
8. Questionnaire Fluid IV boluses
Fluid for maintenance therapy
Fluid volumes administered
Nasogastric loss replacement
Weights
9. 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
10. RESULTS Ages 2-14 (median 10, IQR 8-11.25).
11. MANAGEMENT BEFORE SURGERY 97 had plasma electrolytes on admission
97 commenced on fluids on admission.
21 had [Na] < 135mmol.l-1
12. Fluid volumes; 4,2,1,ml.kg.hr-1
13. Fluid boluses 10-20mls.kg-1
PPS =4.5% human albumin solution.
14. MANAGEMENT DURING SURGERY
16. Fluid boluses 5-20 mls.kg-1
17. MANAGEMENT AFTER SURGERY
19. Fluid boluses Volumes 5-20mls.kg-1
20. BIOCHEMICAL MONITORING On admission: 97 patients
No monitoring: 3 patients
Only once: 54 patients.
Daily monitoring: Nil
21. 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
22. Repeat monitoring [Na] < 130mmol.l-1
< 6 hours: 1 patient
[Na] < 135mmol.l-1
< 24 hours: 17 occasions
Not repeated 10 patients
23. Maintenance fluid and [Na]<135mmol.l-1. Admission
21/21 patients prescribed hypotonic solutions
[0.45% NaCl + 5% dextrose] +/- KCl
24. Maintenance fluid and [Na]<135mmol.l-1. During hospital stay
26/27 prescribed hypotonic fluid
25. Nasogastric losses Nasogastric losses significant; 3 pts.
Replacement; 0.9% NaCl
26. Body Weight 100 patients weighed on admission.
No daily recordings.
27. Charts 99% fluid balance charts.
98% intravenous fluid charts.
90% anaesthetic charts.
28. 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.
29. Thankyou.
Any questions?