Impact of NPSA guidelines on intravenous fluid prescription in children – A retrospective audit on fluid prescription in children undergoing appendicectomy
Authors: Mani V. , Peutrell J. , Snaith R. 
Published: June 2009

Objectives:  To determine if intravenous (IV) fluid and electrolyte monitoring practice has changed in our children's hospital since the introduction of guidelines by the National Patient Safety Agency.

Introduction:  In March 2007, the National Patient Safety Agency (NPSA) published guidelines for clinicians involved in IV fluid prescribing to reduce the risk of hyponatraemia and harm to children. Key recommendations were to use 0.9% sodium chloride (NaCl) for resuscitation boluses; isotonic maintenance IV fluids should be prescribed to those at risk of hyponatraemia; plasma electrolytes should be measured prior to commencing fluids and at least daily subsequently; fluid balance and weight should be accurately recorded; gastro‐intestinal losses should be replaced with NaCl 0.9%. A retrospective audit of IV fluid management in appendectomy patients admitted prior to the NPSA publication was previously completed in our tertiary referral children's hospital (audit1) [2], showing significant discrepancies in clinical practices when compared to the new guidelines. A second retrospective audit has now been completed in our hospital to determine if practices have subsequently changed since the dispersal and implementation of the guidelines.

Method:  We reviewed 50 consecutive notes available in the medical records department of children who had undergone appendectomy between October 2007 and October 2008. We used a structured questionnaire (identical to that used in audit 1) [2] to review three time periods: the preoperative period; intraoperative period and the postoperative period. We recorded the fluid types and volumes given as resuscitation boluses, maintenance fluids and nasogastric loss replacement; the frequency and timing of plasma electrolyte measurements; the relationship, if any, between plasma sodium [Na] concentration and the IV fluid prescribed and biochemical monitoring; and when the patient had been weighed. We then compared the results to those found in audit 1 [2], to see if there were any changes in the practice of intravenous fluid prescription.

Results:  A total of 49 patients had acute appendicitis; one underwent interval appendectomy. The median age was 9.5 years (range 2–13 years).

·Plasma electrolyteswere measured in 98% of patients on admission prior to commencing IV fluids (c.f. 97% in audit 1) [2]. Plasma[Na] was <135mmol l‐1 in eight patients at admission. A further six (12%) patients with plasma [Na] concentration >135mmol l‐1 initially on admission subsequently developed hyponatraemia (c.f. 6% in audit 1) [2].

·Plasma electrolyteswere measured daily in only 14% patients receiving IV fluids (similar to audit 1) [2].

·Fluid boluses were isotonic on all occasions and all were accurately calculated according to weight, (520mls kg‐1) (similar to audit 1) [2].

·Maintenance fluidsbefore surgery were hypotonic in 78% patients. During surgery, 10% of patients received hypotonic maintenance fluid (c.f. 29% in audit 1) rather than the recommended isotonic fluid. After surgery, 56% of patients received solely hypotonic fluids (84% in audit 1) [2]. All maintenance fluids were appropriately calculated according to weight using the Holiday and Segar formula [3]. Hypotonic maintenance fluids were continued in 8/14 (57%) patients with documented hyponatraemia (88% in audit 1) [2].

·Nasogastric losseswere replaced with NaCl 0.9% in the three patients in which these were significant.

· All patients were weighedon admission but none subsequently.

Conclusions:  Practice has changed since the implementation of the NPSA guidelines, but there still discrepancies in management, particularly the frequency of electrolyte monitoring, fluid choice in children with documented hyponatraemia and additionally choice of postoperative maintenance fluid. There is still a need for improvement in perioperative fluid management in children to comply with the NPSA standards.