Patient Safety Tip of the Week
May 28, 2013 The Neglected Medications: IV Fluids
For years we have
pointed out that we often neglect to consider some interventions as
“medications”. These include oxygen, heparin flushes, and IV fluids. We’ve
often written about the issues with oxygen therapy and heparin flushes but we
really haven’t done much with IV fluids.
So what’s the big
deal about IV fluids? Well, NICE (UK’s National Institute for Health and
Care Excellence) has pointed out that the quality and patient safety issues
surrounding IV fluid therapy are so significant that they have just issued new
draft guidelines for managing IV fluids (NICE
2013). They note that a study done in 1999 (NCEPOD 1999) had called
attention to inadequacies in IV fluid management but that little progress has
been made since (Findlay
2011).
Think about your own
organization. You probably don’t consider IV fluid mismanagement as a
“medication error” and therefore probably have no way of tracking how often
such occur. But think about your RCA’s, case reviews, peer reviews, and M&M
rounds. How often have you seen cases where your colorectal surgery patients go
into pulmonary edema on POD 3 or 4? Or patients who become profoundly
dehydrated during hospitalization because of inadequate attention to fluid balance?
Or sepsis patients who get inadequate or untimely fluid resuscitation? Or
patients who fall because of orthostatic hypotension where dehydration is a
contributing factor? Or patients who develop electrolyte disturbances or
aggravation of renal insufficiency? We’ll also bet that the majority of
discharge summaries on your CHF patients fail to mention the “dry weight”
(presumably representing the optimal fluid balance state for that patient). Get
the picture? The problems with fluid management are fairly widespread but,
because we don’t measure and track them, we continue to ignore them.
Quoting the NICE
guideline: “Errors in prescribing IV fluids and electrolytes are particularly
likely in emergency departments, acute admission units, and general medical and
surgical wards because staff in these areas often have less relevant expertise
than those in operating theatres and critical care units. Surveys have shown
that many staff who prescribe IV fluids know neither the likely fluid and
electrolyte needs of individual patients, nor the specific composition of the
many choices of IV fluids available to them. Standards of recording and
monitoring IV fluid and electrolyte therapy may also be poor in these settings.
IV fluid management in hospital is often delegated to the most junior medical
staff who frequently lack the relevant experience and may have received little
or no specific training on the subject.”
The 1999 NCEPOD
(National Confidential Enquiry into Perioperative Deaths) report noted that
as many as one in five patients on IV fluid/electrolyte therapy suffer
complications or morbidity due to their inappropriate administration (NCEPOD 1999). That
report recommended that fluid prescribing be elevated to the same status as
drug prescribing. A more recent NCEPOD report (Findlay
2011) showed that the 30 day mortality in those patients in whom the with
inadequate pre-operative fluid management was 20.5% compared to 4.7% mortality
in those with adequate pre-operative fluid therapy, reinforcing previous
evidence of the beneficial effects of optimisation of fluid status prior to
surgery.
We continue to see
wide variation in the types of IV fluids used, rates, parameters, and
indications and rationales for IV fluid regimens in our hospitals. Development
of standardized order sets, whether paper-based or CPOE-based, had helped
reduce the variation somewhat but considerable variation in practice patterns
persists. Fluid management often appears to be an afterthought.
The NICE draft
guideline has a short
version, full
version, and a document with evidence
and appendices. They appropriately point out that many IV fluid therapy
practices were historically seldom evidence-based nor subject to the randomized
controlled clinical trials we expect for drug therapies. They do grade the
strength of the recommendations they make in the guideline.
The guideline
stresses the “5 R’s”: Resuscitation, Routine maintenance, Replacement,
Redistribution, and Reassessment. It offers separate algorithms for:
(1) assessing a patient’s fluid and electrolyte needs, (2) resuscitation with
fluids, (3) routine fluid maintenance, and (4) addressing existing deficits or
excesses or ongoing abnormal losses. It provides a nice diagram demonstrating sources
of ongoing fluid losses and discusses monitoring parameters and
frequencies. It also recommends that your organization adopt reporting of critical incidents resulting
from fluid mismanagement (it
actually includes a table listing which consequences of fluid management should
be considered for reporting).
The guideline has
lots of recommendations regarding education, training, inservicing, and competency
assessment for fluid management. It recommends that each organization or
facility designate a lead person to oversee, audit and review IV fluid
prescribing and patient outcomes.
It begins with the
logical statement that you should only
prescribe IV fluids where a patient’s needs cannot be met by oral or enteral
routes and you should stop them as soon as
possible. We often see patients in our hospitals receiving IV fluids when they
don’t really need them. Note that in the US we often see inappropriate
initiation of IV fluids to meet the criteria of utilization management
guidelines! For example, the “criteria” for admission or continued
hospitalization might “require” IV fluids at least at a certain rate. So we see
lots of orders written for patients not really needing rates that high or not
even needing IV fluids at all.
The algorithm for
assessment and reassessment is quite good and includes many parameters and
clinical and laboratory signs that might suggest the need for more aggressive
fluid resuscitation, such as the NEWS score (see our September 11, 2012 Patient
Safety Tip of the Week “In
Search of the Ideal Early Warning Score” for links to all our previous
columns on early warning scores). The guideline also offers advice on when to
assess things like urine sodium or look for hyperchloremic acidosis, etc.
It has good
recommendations into consideration of various clinical and laboratory
parameters in determing the best compostion of the IV fluids. It has good
information about what to include in IV fluids (eg. including some glucose in
maintenance IV fluids helps limit starvation ketosis) and what not to include
(eg. recent large randomised controlled trials suggest that crystalloids are
superior to 6% hydroxyethyl starch for resuscitation and the latter increases
mortality and complication rates).
The guideline also
stresses that when patients are transferred to another service or location, a
review of their fluid status and management should be part of the handoff.
We have some of our
own comments about the guideline and about fluid management in general.
First, we are delighted
to see one specific clinical test included in the assessment algorithm of the
NICE guideline. That is the passive leg raising test. Back in the late
1970’s, armed with just a little knowledge about baroreceptor physiology, we
used to challenge our colleagues who relied upon pulmonary capillary wedge
pressure measurements via invasive Swan-Ganz catheters vs. our using the simple
bedside passive leg raising maneuver. We were usually able to predict better
than the Swan-Ganz which patients needed more fluid vs. which ones already had
too much! It’s great to see this simple useful bedside test make its way into
these protocols.
We’re also happy to
see they have included assessment for postural hypotension in their
assessment algorithm. We can’t tell you how many patients with syncope or
dizziness we have seen over the years where no one had bothered to check for
postural hypotension. And even in those rare patients in whom the physician has
ordered monitoring for postural hypotension, it is rarely assessed in the
proper manner. For the proper technique you can go to one of our many tirades
on the topic of orthostatic hypotension (the most recent being in our January
15, 2013 Patient Safety Tip of the Week “Falls
on Inpatient Psychiatry”).
The NICE guideline
makes almost no mention of use of technology. We actually suspect that
problems managing fluid status may have actually worsened as an unintended consequence
of technology. In the old days, the first thing we saw when we opened a
patient’s chart or walked into their room was a flow sheet that had
their vital signs, their I&O’s (input and output), and their weight all
represented in graphic form. It was pretty easy to spot bothersome trends. Many
of today’s EHR’s, however, don’t provide such graphically displayed data (or at
least don’t make it easy to get to such displays in just a click).
Theoretically, computers should make it easier to track fluid status. The
computer should be able to be programmed to compare the fluid input to the
measured output and perform a calculation of the estimated insensible losses,
then display the net fluid deficit or excess in a graphic form along with the
patient’s weight. You could even program in alerts when deficits or excesses
are above whatever limit you set (or at least display those unwanted values in
red), keeping in mind we want to avoid alert fatigue. So IT vendors get with
it!!!
Another somewhat
surprising barrier to accurate I&O recording has been the change in the
nature of the nursing shift. Traditionally we have been used to ordering
“Intake and Output qShift” and were used to seeing the values recorded every 8
hours. Now that 12-hour shifts (and other alternatives) have appeared, the
recordings are less frequent and it is more difficult to promptly see any
trends. For example, if we round on our patients at 7AM and 5PM we might now
see only one I&O recording for the current day and not recognize until the following
morning that there is a disparity.
Not everyone needs
I&O’s measured every day. It is time-consuming for nurses to do these
measurements. So, while it may be important to order I&O’s when a patient
is first begun on IV fluids, their fluid status and the need for frequent
continued measurements should be reassessed daily. As they stabilize,
particularly when they get to the routine maintenance stage, you should
consider whether the monitoring frequency can be reduced.
Note that the
currently issued NICE guideline is a “draft” and might change prior to final
implementation. So you should check back with the NICE website in a few months
(anticipated publication date is November 2013) to see if any substance changes
have been made. But the draft document is an excellent start and should get you
thinking about ways to improve fluid management in hospitalized patients in
your organization. We think you’ll find the algorithms and recommendations very
helpful. It’s a nuts and bolts type document that takes a very practical
approach to an area of patient safety that we have all overlooked for far too
long.
References:
NICE (UK’s National
Institute for Health and Care Excellence). Intravenous fluid therapy: guideline
consultation. (draft guideline) May 21, 2013
http://www.nice.org.uk/guidance/index.jsp?action=folder&o=63877
short version
http://www.nice.org.uk/_gs/link/?id=C25F6090-FAE9-78EB-9C5508BC41237F8D
full version
http://www.nice.org.uk/_gs/link/?id=C25E812D-BB27-7D64-638292059933DF8E
evidence and
appendices
http://www.nice.org.uk/_gs/link/?id=C25EF0FE-CFA6-3E16-A185D7DFCD914F95
NCEPOD (National
Confidential Enquiry into Perioperative Deaths). Extremes of age: the 1999
report of the National Confidential Enquiry into Perioperative Deaths, 1999
http://www.ncepod.org.uk/pdf/1999/99full.pdf
Findlay GP, Goodwin
APL, Protopapa K, et al. Knowing the Risk: A review of the peri-operative care
of surgical patients. A report by the National Confidential Enquiry into
Patient Outcome and
Death (2011)
http://www.ncepod.org.uk/2011report2/downloads/POC_fullreport.pdf
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