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Dr Rosie Snaith Dr J. Peutrell. June 2007

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.

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Dr Rosie Snaith Dr J. Peutrell. June 2007

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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

  15. Fluid boluses • 5-20 mls.kg-1

  16. MANAGEMENT AFTER SURGERY

  17. Fluid boluses • Volumes 5-20mls.kg-1

  18. BIOCHEMICAL MONITORING • On admission: 97 patients • No monitoring: 3 patients • Only once: 54 patients. • Daily monitoring: Nil

  19. 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

  20. Repeat monitoring • [Na] < 130mmol.l-1 < 6 hours: 1 patient • [Na] < 135mmol.l-1 < 24 hours: 17 occasions Not repeated 10 patients

  21. Maintenance fluid and [Na]<135mmol.l-1. Admission • 21/21 patients prescribed hypotonic solutions • [0.45% NaCl + 5% dextrose] +/- KCl

  22. Maintenance fluid and [Na]<135mmol.l-1. During hospital stay • 26/27 prescribed hypotonic fluid

  23. Nasogastric losses • Nasogastric losses significant; 3 pts. • Replacement; 0.9% NaCl

  24. Body Weight • 100 patients weighed on admission. • No daily recordings.

  25. Charts • 99% fluid balance charts. • 98% intravenous fluid charts. • 90% anaesthetic charts.

  26. Conclusions • [Na] <135mmol.l-1in 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.

  27. Thankyou. • Any questions?

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