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Intravenous fluid therapy for adults in hospital: summary - The BMJ

14 déc 2013 · electrolyte needs are fundamental to good patient care • Assess intravenous ( IV) fluid therapy only for patients whose BP=blood pressure

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BMJ | 14 DECEMBER 2013 | VOLUME 347 33

PRACTICE

National Clinical Guideline Centre,

Royal College of Physicians, London

NW? ?LE, UK

Southampton University Hospitals

NHS Trust, Southampton SO??

?YD, UK

Correspondence to: S Padhi

smita.padhi@rcplondon.ac.uk

Cite this as: ????;???:f????

doi: ??.????/bmj.f????

This is one of a series of BMJ

summaries of new guidelines based on the best available evidence; they highlight important recommendations for clinical practice, especially where uncertainty or controversy exists.

Further information about the

guidance, a list of members of the guideline development group, and the supporting evidence statements are in the full version on bmj.com.Many hospital sta? who prescribe intravenous (IV) ?uids have not received adequate training on the subject despite the fact that ?uid management is one of the commonest tasks in hospital involving complex decisions on opti- mal volume, rate, and type of ?uid to be given. Although in appropriate ?uid therapy is rarely reported as being responsible for patient harm, a ???? report from the National Con?dential Enquiry into Perioperative Deaths (NCEPOD) suggested that as many as ? in ? patients receiv- ing IV ?uids in hospital su?ered complications or morbid- ity due to their inappropriate administration.

A more

recent N CEPOD report in ???? highlighted that patients were at an increased risk of death within thirty days of h aving an operation if they had received inadequate or excessive IV ?uids in the preoperative period. This article summarises recent recommendations from the National Institute for Health and Care Excellence (NICE).

Recommendations

NICE recommendations are based on systematic reviews

of the best available evidence and explicit consideration of cost e?ectiveness. When minimal evidence is available,

recommendations are based on the Guideline Develop- ment Group's experience and opinion of what constitutes good practice. Evidence levels for the recommendations are in the full version of this article on bmj.com. Principles and protocols for intravenous fluid therapy The assessment and management of patients' ?uid and electrolyte needs are fundamental to good patient care.

Assess and manage patients' ?uid and electrolyte

needs as part of every ward review. Provide intravenous (IV) ?uid therapy only for patients whose needs cannot be met by oral or enteral routes, and stop as soon as possible.

Skilled and competent healthcare professionals

should prescribe and administer IV ?uids and assess and monitor patients receiving IV ?uids.

When prescribing IV ?uids, remember the ?ve Rs:

resuscitation, routine maintenance, replacement, redistribution, and reassessment. O?er IV ?uid therapy as part of a protocol (see ?gure):

Assess patients' ?uid and electrolyte needs

following algorithm ? (assessment) If patients need IV ?uids for resuscitation, follow algorithm ? (?uid resuscitation) If patients need IV ?uids for routine maintenance, follow algorithm ? (routine maintenance) If patients need IV ?uids to address existing de?cits or excesses, ongoing abnormal losses, or abnormal ?uid distribution, follow algorithm ? (replacement and redistribution).

GUIDELINES

Intravenous fluid therapy for adults in hospital:

summary of NICE guidance

Smita Padhi,

1

Ian Bullock,

1

Lilian Li,

1

Mike Stroud,

2 on behalf of the Guideline Development Group

Include the following information in IV ?uid

prescriptions:

The type of ?uid to be administered

The rate and volume of ?uid to be administered.

Patients should have an IV ?uid management plan,

which should include details of: The ?uid and electrolyte prescription over the next ?? hours

The assessment and monitoring plan.

Initially, the IV ?uid management plan should be

reviewed by an expert daily. IV ?uid management plans for patients receiving longer term IV ?uid therapy whose condition is stable may be reviewed less frequently.

When prescribing IV ?uids and electrolytes, take

into account all other sources of ?uid and electrolyte intake, including any oral or enteral intake, and intake from drugs, IV nutrition, blood, and blood products. Patients have a valuable contribution to make to their ?uid balance. If a patient needs IV ?uids, explain the decision and discuss the signs and symptoms they need to look out for if their ?uid balance needs adjusting. If possible or when asked, provide written information (for example, NICE's information for the public), and involve the patient's family members or carers (as appropriate).

Assessment and monitoring

Initial assessment

Assess whether the patient is hypovolaemic.

Algorithm ? (see ?gure) outlines the indicators that a patient may need urgent ?uid resuscitation. Assess the patient's likely ?uid and electrolyte needs from their history, clinical examination, current medications, clinical monitoring, and laboratory investigations - see Algorithm ?.

Reassessment

If the patient is receiving IV ?uids for resuscitation, reassess the patient using the ABCDE approach (airway, breathing, circulation, disability, exposure); monitor respiratory rate, pulse, blood pressure, and perfusion continuously; and measure venous lactate level or arterial pH and base excess according to the Resuscitation

Council's guidance on advanced life support.

All patients continuing to receive IV ?uids need

regular monitoring. This should initially include at least daily reassessments of clinical ?uid status, laboratory values (urea, creatinine, and electrolytes), and ?uid balance charts, along with weight measurement twice weekly. Be aware that: Patients receiving IV ?uid therapy to address replacement or redistribution problems may need more frequent monitoring

Previous articles in

this series ?Secondary prevention for patients a?er a myocardial infarction: summary of updated

NICE guidance

(BMJ ????;???:f????) ?Management of urinary incontinence in women: summary of updated NICE guidance (BMJ ????;???:f????) ?Management of autism in children and young people: summary of NICE and SCIE guidance (BMJ ????;???:f????) ?Acute kidney injury: summary of NICE guidance (BMJ ????;???:f????) ?Diagnosis and management of varicose veins in the legs: summary of NICE guidance (BMJ ????;???:f????)

34 BMJ | 14 DECEMBER 2013 | VOLUME 347

PRACTICE

monitoring frequency should be detailed in their

IV ?uid management plan.

If patients have received IV ?uids containing chloride concentrations >??? mmol/L (such as sodium chloride ?.?%), monitor their serum chloride concentration daily. If patients develop hyperchloraemia or acidaemia, reassess their IV ?uid prescription and assess their acid-base status. Consider less frequent monitoring for patients who are stable. Clear incidents of ?uid mismanagement (for example, unnecessarily prolonged dehydration or inadvertent ?uid overload due to IV ?uid therapy) should be reported through standard critical incident reporting to encourage improved training and practice.

Additional monitoring of urinary sodium

may be helpful in patients with high volume gastrointestinal losses: reduced urinary sodium excretion (Patients receiving longer term IV ?uid therapy whose condition is stable may be monitored less frequently, although decisions to reduce

Using an ABCDE (Aitrway, Breathing, Circulation, Disability, Exposure) approacht, assess whether pattient is hypovolaemic tand needs fluid resuscitation

Assess volume status ttaking into account clinical examinattion, trends, and cotntext. Indicators that a patient mtay need fluid resuscitation include: tsystolic BP

heart rate >?? beats/mint; capillary re?ll >? seconds or peripheries tcold to touch; respiratory rate >?? breaths/mitn; NEWS ≥?; ??° passive leg raisting suggests fluid retsponsiveness

Prescribe by addintg to or subtracting frtom routine maintenancte, adjusting for all otther sources of fluid and electrtolytes (oral, enteral, and drug tprescriptions)

Monitor and reassesst fluid and biochemical status by clinical and laboratory monitoring

Ensure nutrition and tfluid needs are me

t

Also see Nutrition suptport in adults

(NICE clinical guidetline ??)Does patient have comtplex fluid or electrolytte replacement or abnortmal distribution issutes Look for existing de?tcits or excesses, ontgoing abnormal losses, abnormal disttribution, or other comtplex issues Assess patient"s liktely fluid and electrolytte need s History: previous tlimited intake, thirstt, abnormal losses, ctomorbidities

Clinical examinatiton: pulse, BP, capiltlary re?ll, JVP, oedtema (peripheral or ptulmonary), postural hytpotensio

n Clinical monitoringt: NEWS, fluid balancet charts, weight Laboratory assessmtents: FBC, urea, crteatinine and electrotlyte s Can patient meet theitr fluid and/or electrotlyte needs orally or tenterally?No No NoYes NoYes Ye s Ye sNoYes

Initiate treatmentG

Identify cause oGf de?cit and respoGnse

Give a fluid bolusG of ??? mL of crystaGlloid

(containing soGdium in range of ???-??? mmol/L) Gover ?? minutes

Reassess patient uGsing the ABCDE appGroach

Does patient stillG need fluid resuscGitation?

Seek expert help iGf unsure

Give a further fluiGd bolus of

???-??? mL of crystalGloid

Redistribution and Gother complex issuGe

s

Check for

Gross oedema

Severe sepsi

s

Hypernatraemia oGr hyponatraemia

Renal, liver, or Gcardiac impairmen

t

Postoperative fluGid retention and rGedistributio

n

Malnourished andG refeeding issues

Seek expert help iGf necessary and esGtimate

requirementsOngoing abnormal flGuid or electrolyteG lossesCheck ongoing lossGes and estimate amGounts

Check for

Vomiting and NG tGube loss

Biliary drainageG loss

High or low volumGe ileal stoma lossG

Diarrhoea or excGess colostomy lossG

Ongoing blood losGs, such as melaenaG

Sweating, fever, Gor dehydration

Pancreatic, jejuGnal ?stula, or stoGma loss

Urinary loss, suGch as post-AKI polGyuri

aExisting fluid or Gelectrolyte de?citGs or excesses

Check for:

Dehydration

Fluid overload

Hyperkalaemia orG hypokalaemia

Estimate de?cits oGr excesses

IV=intravenous. ABCGDE=airway, breathinGg, circulation, diGsability, and exposGure. NEWS=National Early WaGrning Score. BP=bloGod pre

ssure. JVP=jugularG venous pressure FBC=full blood counGt. NG=nasogastric. GAKI=acute kidney iGnjury NoYes

Does patient have

signs of shock?

Seek expert help

>???? mL given?Algorithm ?: assesusement

Algorithm ?:

fluid resuscitation

Give maintenance IVG fluids

Normal daily fluidG and electrolyte rGequirements: ??-?? mL/kg/day watGer ? mmol/L/kg/day sodGium, potassium, chGloride ??-??? g/day glucosGe (for example, glGucose ?% contains ? g/??? GmL)

Reassess and monitGor patient

Stop IV fluids wheGn no longer neededG

Nasogastric fluidsG or enteral feedinGg are preferable when maintenanceG needs are more thGan ? daysAlgorithm ?: routine maintenanceu

Algorithm ?:

replacement and redistribution

Algorithms for IV fluid therapy

BMJ | 14 DECEMBER 2013 | VOLUME 347 35

PRACTICE

and delivering IV ?uid therapy are trained on the principles covered in this guideline, and are then formally assessed and reassessed at regular intervals to demonstrate competence in:

Understanding the physiology of ?uid and

electrolyte balance in patients with normal physiology and during illness

Assessing patients' ?uid and electrolyte needs

(the ?ve Rs: resuscitation, routine maintenance, replacement, redistribution, and reassessment)

Assessing the risks, bene?ts, and harms of IV

?uids

Prescribing and administering IV ?uids

Monitoring the patient response

Evaluating and documenting changes

Taking appropriate action as required.

Healthcare professionals should receive training and education about, and be competent in, recognising, assessing, and preventing consequences of mismanaged IV ?uid therapy, including:

Pulmonary oedema

Peripheral oedema

Volume depletion and shock.

Hospitals should have an IV ?uids lead, responsible for training, clinical governance, audit, and review of IV ?uid prescribing and patient outcomes.

Overcoming barriers

Implementing this guideline will require all clinicians to acknowledge and understand that intravenous ?uid therapy is a key area of patient care, and to make consist- ent e?orts to ensure compliance with the recommenda- tions. Challenges to the identi?cation of adverse events in hospitals as consequences of mismanagement of intra- venous ?uid therapy will include di?culties in estab- lishing causal relationships between the two. However, careful monitoring of patients in line with the recom- mendations and recording of relevant observations will establish safe and e?ective care, removing the current variations in both practice and outcome. Perceptions among clinicians with regard to the use of tetrastarch for ?uid resuscitation will also need re-evaluation in light of the evidence presented. Contributors: SP wrote the ?rst dra?. All authors reviewed the dra?, were involved in writing further dra?s, and reviewed and approved the ?nal version for publication. SP acts as guarantor. Competing interests: We have read and understood the BMJ policy on declaration of interests and have no relevant interests to declare. Provenance and peer review: Commissioned; not externally peer reviewed. National Confidential Enquiry into Perioperative Deaths. Extremes of age: the ???? report of the National Confidential Enquiry into Perioperative Deaths. NCEPOD, ????. www.ncepod.org.uk/ pdf/????/??full.pdf. National Confidential Enquiry into Perioperative Deaths. Knowing the risk: a review of the peri-operative care of surgical patients. NCEPOD, ????. www.ncepod.org.uk/????report?/downloads/POC_fullreport. pdf. National Institute for Health and Care Excellence. Intravenous fluid therapy for adults in hospital. (Clinical guideline ???.) ????. www. nice.org.uk/CG???. Resuscitation Council (UK). Advanced life support. ?th ed.

Resuscitation Council (UK), ????.

National Institute for Health and Care Excellence. Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition. (Clinical guideline ??.) ????. www.nice.org.uk/CG??. If patients are transferred to a di?erent location, reassess their ?uid status and IV ?uid management plan on arrival in the new setting.

Fluid resuscitation

If patients need IV ?uid resuscitation, use

crystalloids that contain sodium in the range ???- ??? mmol/L, with a bolus of ??? mL over less than ?? minutes (see Algorithm ? in the ?gure for details).

Do not use tetrastarch for ?uid resuscitation.

Consider human albumin solution ?-?% for ?uid

resuscitation only in patients with severe sepsis.

Routine maintenance

If patients need IV ?uids for routine maintenance

alone, restrict the initial prescription to: ??-?? mL/kg/day of water and

Approximately ? mmol/kg/day of potassium,

sodium, and chloride and

Approximately ??-??? g/day of glucose to limit

starvation ketosis. (This quantity will not address patients' nutritional needs; see NICE clinical guideline on nutrition support in adults (CG??).

See Algorithm ? in ?gure for detail.

For patients who are obese, adjust the IV ?uid

prescription to their ideal body weight. Use lower range volumes per kg (patients rarely need more than a total of ? litres of ?uid per day) and seek expert help if their body mass index is >??.

Consider prescribing less ?uid (for example,

??-?? mL/kg/day ?uid) for patients who:

Are older or frail

Have renal impairment or cardiac failure

Are malnourished and at risk of refeeding

syndrome (see NICE clinical guideline on nutrition support in adults (CG??)

When prescribing for routine maintenance alone,

consider using ??-?? mL/kg/day sodium chloride ?.??% in ?% glucose with ?? mmol/L potassium on day ? (there are other regimens to achieve this). Prescribing >?.? L/day increases the risk of hyponatraemia. These are initial prescriptions, and further prescriptions should be guided by monitoring. Consider delivering IV ?uids for routine maintenance during daytime hours to promote sleep and wellbeing.

Replacement and redistribution

Adjust the IV prescription (add to or subtract from maintenance needs) to account for existing ?uid or electrolyte de?cits or excesses, ongoing losses, or abnormal distribution (see Algorithm ? in ?gure).

Seek expert help if patients have a complex ?uid

or electrolyte redistribution issue or imbalance, or substantial comorbidity (Algorithm ? outlines examples, including gross oedema and severe sepsis).

Training and education

Hospitals should establish systems to ensure that

all healthcare professionals involved in prescribing

36 BMJ | 14 DECEMBER 2013 | VOLUME 347

PRACTICE

10?MINUTE CONSULTATION

Dental pain

Yvonne MacAuley,

1

Patrick O'Donnell,

2

Henry F Duncan

3

Dublin Dental University Hospital,

Lincoln Place, Dublin ?, Ireland

Graduate Entry Medical School,

University of Limerick, Limerick,

Ireland

Division of Restorative Dentistry

and Periodontology, Dublin Dental

University Hospital, Trinity College

Dublin, Ireland

Correspondence to: Y MacAuley

yvonne.macauley@hotmail.com

Cite this as: ????;???:f????

doi: ??.????/bmj.f????

This is part of a series of occasional

articles on common problems in primary care. The BMJ welcomes contributions from GPs. A ?? year old woman presents complaining of severe dental pain and swelling, and is unable to contact her dentist. She reports that the pain started three days ago and has increased in intensity since, with her face becoming swollen in the last ?? hours.

What you should cover

Nature and severity of the pain

Dental pain occurs as a result of in?ammation of the pulp (pulpitis) (see ?gure). This is generally caused by bacte- ria from decayed teeth or defective dental ?llings. Den- tal pain can be practically grouped into ?ve progressive pain categories. A short pain history and examination is required to categorise this pain. ?. A short, sharp pain lasting only a few seconds and occurring in response to a cold or "sweet" stimulus is likely to be reversible pulpitis. This is generally not a severe problem, and the pulp of the tooth can be saved. Antibiotics and analgesics are not required, but the patient should be advised to attend a dentist. ?. A dull, aching, "pulsing" pain that occurs spontaneously and in response to thermal stimuli is likely to be irreversible pulpitis. There is no swelling, but pain is debilitating, o?en disturbs sleep, and may last for hours. Irreversible pulpitis requires expedient dental intervention. Antibiotics and analgesics are ine?ective. ?. Untreated pulpitis leads to pulp necrosis and death, and the pain may temporarily decrease.

However, in?ammation and infection of the

surrounding tissues, known as apical periodontitis, will ensue as bacterial and pulp breakdown products escape from the tooth. The o?ending tooth will be tender to touch or pressure. The tooth may respond to antibiotics, but they are not essential.

Dental intervention is still required.

?. An acute apical abscess is a common manifestation of untreated apical periodontitis and is associated with a swelling, tooth mobility, and severe tenderness to touch. Conversely, a chronic apical abscess may be present without pain or obvious swelling if the infection is draining.

Chronic abscesses usually drain intra-orally but

occasionally can appear as a skin "pimple" extra- orally. Acute apical abscesses will require drainage by a dentist but will be relieved in the short term by antibiotics. ?. Acute abscesses may spread as a cellulitis within so? tissue spaces to the ?oor of the mouth (Ludwig's angina), leading to neck and mediastinalquotesdbs_dbs10.pdfusesText_16