Fluid Guidelines: Who needs them? Dr. Marcia McDougall Fluid Lead - PowerPoint PPT Presentation

Fluid Guidelines: Who needs them? Dr. Marcia McDougall Fluid Lead NHS Fife

Disclosure I have received honoraria from Baxter for educational talks about fluid guideline development (FORTE education meetings). Acknowledgements Professor Dileep Lobo, Professor Robert Hahn Dr. Aminda da Silva, Southampton Fluid Guidelines

Overview  Is there a problem?  What should we be doing?  Guidance around fluid management  Action in Fife  Demonstrating impact

Is there a problem?

1999  Elderly patients are dying as a result of poor fluid management  (New) doctors have inadequate knowledge and sub-optimal prescribing skills  Fluid prescription must be given the same status as drug prescription.

A Big Issue Poor fluid management contributed to many of the deaths SASM Report 2008 Mortality review Midlands: 20% of deaths had contributory fluid errors OPAH report 2014: no Scottish hospitals chart fluid balance accurately; fluids are a problem Up to 20% of patients suffer morbidity from fluid administration. NICE draft Quality Indicators March 2014 Has s anyt ything ing chang nged ed sin ince ce 199 999? 9?

Fluid Prescribing  Usually done by juniors with little support  Regarded as a task of low importance  Pile of fluid charts to ‘fill in’  Poor knowledge of fluid content/requirements  Juniors felt teaching on fluids is poor  Confidence in prescribing was poor Powell, Drummond 2011 Unpublished survey, Edinburgh

Paracelsus Poison is in everything, and no thing is without poison. The dosage makes it either a poison or a remedy. (1493-1541)

The right amount of the right fluid at the right time

Too wet

Too dry AKI

Varadhan & Lobo, Manual for Fast-track Recovery in Colorectal Surgery 2011

Traditional teaching  2 x 5%glucose to 1 x 0.9% saline  Quickly becomes saline saline saline  Potassium generally not prescribed  Saline for resuscitation/replacement in A&E and medicine  Balanced crystalloids in use in anaesthetics/critical care  Do we use balanced crystalloids correctly?

British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients J. Powell Tuck, Peter GIFTASUP 2007 (Revised Gosling, Dileep Lobo, 2011) c Jeremy Powell-Tuck (chair)1, Peter Gosling2, Dileep N Lobo1,3 Simon Gordon Carlson, P Allison1, Gordon L Carlson3,4, Marcus Gore3, Andrew J Lewington5, Rupert M Pearse6, Monty G Mythen6 On behalf of1BAPEN Medical - a core group of BAPEN,2the Andrew Lewington, Association for Clinical Biochemistry,3the Association of Surgeons of Great Britain and Ireland,4the Society of Academic and Research Surgery,5the Renal Association and6the Intensive Care Society . Rupert Pearse, Monty Mythen

Royal College of Physicians  Consensus Statement on Acute Kidney Injury  November 2012 RCPE website  All hospitals must have fluid prescribing guidelines  Recommend balanced salt solutions for replacement and resuscitation

NICE Guidelines Dec 2013  Fluids are important and require careful prescribing  Changes in fluids  Standardise maintenance fluid: should be mostly water e.g. 0.18%NaCl/4%Glucose +/- KCl for ADULTS  Dose maintenance according to weight  Use balanced solutions for replacement/resuscitation  Some evidence building against 0.9% NaCl (acidosis, renal vasoconstriction)  Reassessment is important

Daily Requirements: Maintenance (GIFTASUP/NICE)  Water 25-30 ml/kg  Sodium approx 1 mmol/kg  Potassium approx 1 mmol/kg  Calories minimum 400 Calories= 50-100 g dextrose = 2 bags of 4% or 5% glucose/day

Average Daily Requirements  80 kg man needs: 2400 ml H2O 80 mmol Na + 80 mmol K + 80 mmol Cl -  40kg man needs: 1200 ml H2O 40 mmol Na + 40 mmol K + 40 mmol Cl -

NICE Draft Quality Indicators 1. All hospitals have a fluid lead. 2. Adults on IV fluids are treated by individuals who have been trained and assessed for knowledge and competence in fluid management. 3. Adults on IV fluids have a 24 hour management plan for fluids given and reviewed by a senior clinician including prescription, assessment and monitoring. 4. Consequences of fluid mismanagement are reported as critical incidents and learning is applied.

There is a long way to go in the UK!

Action in Fife

Fife Strategy 2010-15 1. Audits: show problem 2. Raise awareness – several talks 3. Form multidisciplinary group 4. Engage management 5. Get guidelines out June 2012 6. Education: juniors/consultants 7. Appoint a fluid nurse Aug 2013 8. Education 8. Introduce new fluid charts 9. Monitor process and outcomes 10. National spread 11. Second fluid nurse Oct 2015

Audits

Fluid administered per day accounting for losses 16 Number of patient days 14 Mean daily 12 post- operative 10 fluid intake: 8 3021 ml* 6 Standard deviation: 4 1256 ml 2 0 Too little Recommended Too much (+/- 500ml)

14 12 Na per day Number of patient days 10 8 6 4 2 0 2/3 get excess Na 1 patient >800mmol D. Hall SHDU 2010 Na (mmol/day)

per Day Potassium Administered 25 Number of Patient Days 20 15 10 5 0 K (mmol/day) Excess losses not replaced D. Hall SHDU 2010

Mortality Review NHS Fife  May-Oct 2014 13% deaths had a contribution from poor fluid management  Poor fluid balance chart completion  Frail elderly coming to harm from too much/too little fluid  Senior input lacking to fluid therapy  More monitoring needed  Beware fluid restriction – often get <500ml/day

Fife Guidelines June 2012  Adult guidelines only  Maintenance, replacement, resuscitation  Hyponatraemic <132, use PL 148 for maintenance.  Hyponatraemia Guideline on intranet  Give Potassium routinely in maintenance unless rising or high  Diabetes: HHS and DKA protocols unchanged  On IV insulin: use 0.18%NaCl/4% Glucose +KCl for maintenance by weight

The right fluid  Maintenance: mostly water: 0.18%NaCl/4%Glucose/KCl  Replacement: balanced solution/0.9%NaCl  Resuscitation: balanced solution/blood/colloid

Questions to ask before prescribing fluid Assess the patient Does my patient need intravenous fluid ? Why? How much? Which fluid does he need?

Physiology Requirements Assessment Maintenance Replacement Resuscitation

Third Edition of Fife Guidelines • Consistent with NICE December 2013 • Guidelines now in Lothian • Edinburgh University • Endorsed by the Scottish Intensive Care Society • Talks in Birmingham, London, Nottingham, Manchester, Stirling, Aberdeen, Glasgow, Sheffield (some of these as part of Baxter educational programme)

Towards the aim: opportunities for quality improvement Assessment Prescription Charting Administration

Fluid nurse Sept 2013-14  Meghan Bateson supported by R&D grant  Education of nurses  Liaison with nursing and medical management, dieticians  Introduction and monitoring of combined fluid prescription/fluid balance charts: QI methods  Posters: fluid volumes, criteria for fluid balance chart, guidelines, fasting  Supporting junior doctors  OPAH report – high level management engagement

Challenges

Intake / Output Charts  Why do we need new charts?  Current completion unreliable  Ward culture: fluid balance low priority  Documentation varied between wards  Goal setting where appropriate  Triggering escalation when appropriate  Prescription and Fluid balance together

Implementation  Baseline audits prior to chart use  Testing of charts on wards  Education: ANPs, pharmacists nurses, doctors: turnover a challenge  Changing fluid stocks in wards  Posters  Consultant mandatory training  Leadership support

Outcomes: Demonstrating Impact

Process measures  Are the right fluids being prescribed?  The right amount? Ongoing audits  Are fluid balance charts being filled in properly? Ongoing audits - disappointing  Is fluid use changing in line with the guidelines? – Yes, shown by charts

Total Fluid Intake (ml/kg/24hrs) 70 60 50 ml/kg/24 hours Implementation of fluid charts 40 30 20 10 0

Fluid use NHS Fife 9000 SODIUM Start of fluid work CHLORIDE 0.9% 8000 INFUSION Viaflo Guidelines Very busy month 7000 SODIUM LACTATE COMPOUND 6000 INFUSION PL change Charts (Hartmans) 5000 Litres Plasmalyte 4000 3000 SODIUM CHL 2000 0.18%/ GLU 4% 1000 0 Apr-09 Jul-09 Oct-09 Apr-10 Jul-10 Oct-10 Apr-11 Jul-11 Oct-11 Apr-12 Jul-12 Oct-12 Apr-13 Jul-13 Oct-13 Apr-14 Jul-14 Jan-09 Jan-10 Jan-11 Jan-12 Jan-13 Jan-14 Month

L/OBD 0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 Jan-09 Mar-09 May-09 Jul-09 Sep-09 Nov-09 Start of fluid work Jan-10 Quality improvement saving not quantifiable =cost saving of £82000/year on fluids cf 2008 Mar-10 May-10 Jul-10 Sep-10 Nov-10 Very busy month Jan-11 Litres/OBD Mar-11 May-11 Jul-11 Sep-11 Month Nov-11 Jan-12 Guidelines Mar-12 May-12 Jul-12 Sep-12 Nov-12 Jan-13 Mar-13 May-13 Jul-13 Sep-13 Nov-13 Jan-14 Mar-14 Charts May-14 Jul-14