Intravenous fluid therapy: an audit and discussion of improvements required for prescribers and administrators.

BACKGROUND: Foundation doctors and nurses are the clinicians most closely involved in fluid assessment, intravenous (IV) fluid prescription and administration. However, both groups report challenges regarding IV fluids. At a large NHS trust in England, adherence to the National Institute for Health and Care Excellence (NICE) guideline CG174, regarding IV fluids, was largely unknown. AIMS: To assess the baseline adherence, within the hospitals, to CG174 and identify areas for improvement. METHODS: A set of 12 audit standards were developed and used to collect data across 29 clinical areas between September 2022 and May 2023, with 255 patients receiving IV fluids at any time during their inpatient stay included. FINDINGS: For two standards target adherence of 95% was achieved, with an adherence less than 50% in most. Areas of particularly poor adherence included assessing and meeting fluid and electrolyte requirements, patient reassessment and developing IV fluid management plans. CONCLUSION: Trust baseline adherence to NICE CG174 requires improvement, particularly regarding patient assessment and reassessment, and meeting electrolyte requirements.

Association between intravenous fluids during labor and primary postpartum hemorrhage: A retrospective cohort study.

INTRODUCTION: There is a major research gap relating to the impact of intravenous (IV) fluids administration during labor on maternal and neonatal outcomes. It is biologically plausible that a relationship between volume of IV fluids and primary postpartum hemorrhage (PPH) exists. The primary objective of this study was to evaluate whether the administration of high-volume IV fluids during labor (≥ 2500 mL) increases the risk of primary PPH and other adverse outcomes for women with a term, singleton pregnancy, in comparison to low-volume IV fluids during labor (<2500 mL). MATERIAL AND METHODS: A retrospective cohort study was conducted at a tertiary referral hospital in Sydney, Australia between 1st September 2021 and 31st October 2022. Inclusion criteria were: women with a live singleton fetus in a cephalic presentation; planning a vaginal birth; and admitted for labor and birth care between 37 and 42 week gestation. The study factor was IV fluids during labor and the primary outcome was primary PPH ≥500 mL. Secondary outcomes included cesarean section and major perineal injury. Pregnancy, birth, and postnatal data were obtained from the hospital's electronic clinical database, electronic medical records, and paper fluid order documentation. Multivariable logistic regression and multiple imputation were used to explore the relationship between volume of IV fluids in labor and PPH. RESULTS: A total of 1023 participants were included of which 339 had a primary PPH (33.1%). There was no association between high-volume IV fluids and PPH after adjusting for demographic and clinical factors (adjusted odds ratio [ORadj]1.02 95% confidence interval [95%CI] 0.72, 1.44). However, there was a positive association between high-volume IV fluids and cesarean section (ORadj 1.99; 95%CI 1.4, 2.8). CONCLUSIONS: The findings of this research are important to further knowledge relating to the administration of IV fluids during labor. The findings emphasize the importance of accurately documenting IV fluids administration and identifies research priorities to enable us to better understand the broader implications of IV fluids administration on pregnancy and perinatal outcomes.

How to follow the guidelines, when the appropriate fluid is missing?

Intravenous maintenance fluid therapy (IV-MFT) is probably the most prescribed drug in paediatric hospital care. Recently paediatric societies have produced evidence-based practice guidelines that recommend the use of balanced isotonic fluid when prescribing IV-MFT in both acute and critical paediatric care. Unfortunately, the applicability of these guidelines could be called into question when a ready-to-use glucose-containing balanced isotonic fluid is not available. The main objective of this study was to describe the availability of glucose-containing balanced isotonic fluids in European and Middle Eastern paediatric acute and critical care settings. This work is an ancillary study of the survey dedicated to IV-MFT practices in the paediatric acute and critical care settings in Europe and Middle East, a cross-sectional electronic 27-item survey, emailed in April-May 2021 to paediatric critical care physicians across 34 European and Middle East countries. The survey was developed by an expert multi-professional panel within the European Society of Peadiatric and Neonatal Intensive Care (ESPNIC). Balanced isotonic fluid with glucose 5% was available for only 32/153 (21%) responders. Balanced isotonic fluid with glucose 5% was consistently available in the UK (90%) but not available in France, Greece, The Netherlands and Turkey.    Conclusion: Ready-to-use isotonic balanced IV solutions containing glucose in sufficient amount exist but are inconsistently available throughout Europe. National and European Medication Safety Incentives should guarantee the availability of the most appropriate and safest IV-MFT solution for all children. What is Known: • Intravenous maintenance fluid therapy (IV-MFT) is probably the most prescribed drug in paediatric hospital care. • Balanced isotonic fluid is recommended when prescribing IV-MFT in both acute and critical paediatric care. What is New: • Balanced isotonic fluid with glucose 5% is available for less than 25% of the prescribers in Europe and the Middle East. Availability of balanced isotonic fluid with glucose 5% varies from one country to another but can also be inconsistent within the same country. • Clinicians who have access to a ready-to-use balanced isotonic fluid with glucose 5% are more likely to consider its use than clinicians who do not have access to such an IV solution.

Intravenous Hydration and Associated Outcomes in Patients With Sickle Cell Disease Admitted With Vaso-Occlusive Crises: A Systematic Review.

Acute painful vaso-occlusive crisis (VOC) is the common presentation of sickle cell disease (SCD) leading to emergency room visits, admissions, morbidity, mortality, and negative impacts on quality of life. Among various treatment approaches commonly employed to manage the condition, intravenous (IV) hydration is also frequently used in emergency and inpatient settings. Although helpful to overcome dehydration, IV hydration often leads to adverse outcomes like fluid overload, pulmonary edema, increased length of stay, transfer to intensive care unit, new oxygen requirement, etc. Small-scale retrospective studies are conducted to study the outcomes of IV hydration but have failed to conclusively demonstrate its benefits as well as choice of IV fluids, rate of IV fluid replacement, etc. We conduct this review as an attempt to summarize the available evidence on the role and utility of IV hydration in sickle cell crises along with reported adverse outcomes.

A balancing act: drifting away from the reflexive use of "ab"normal saline.

Maintenance intravenous fluids are the most frequently ordered medications for hospitalized children. Since the American Association of Pediatrics published national guidelines, there has been an increased reflexive use of isotonic solutions, especially 0.9% saline, as a prophylaxis against hyponatremia. In this educational review, we discuss the potential deleterious effects of using 0.9% saline, including the development of hyperchloremia, metabolic acidosis, acute kidney injury, hyperkalemia, and a proinflammatory state. Balanced solutions with anion buffers cause relatively minimal harm when used in most children. While the literature supporting one fluid choice over the other is variable, we highlight the benefits of balanced solutions over saline and the importance of prescribing fluid therapy that is individualized for each patient.

Administering Intravenous Fluid in the Immediate Postpartum Period Minimizes Ultimate Formula Feeding.

Background: Human milk is the optimal form of nutrition for infants. Interventions associated with a decreased rate of exposure to infant formula are of benefit. We hypothesized that intravenous (IV) fluids could be associated with a reduction of infant formula when infants are separated from their mother. Methods: Retrospective chart review of term infants admitted to Rady Children's Neonatal Intensive Care Units (NICUs) for possible sepsis who received antibiotic treatment but did not develop sepsis. IV fluid use and formula exposure were analyzed. Results: Six hundred twenty-eight infants met the inclusion criteria. Around 25.6% received IV fluids and 74.4% did not. IV fluid administration was associated with a significantly reduced chance of formula exposure while in the NICU (odds ratio: 0.694, 95% confidence interval: 0.484-0.993; *p = 0.046). Conclusion: This retrospective chart review found that infants transferred to the NICU and separated from their mothers due to chorioamnionitis exposure who received IV fluids were significantly less likely to receive any infant formula than infants who were not administered IV fluids.

Intravenous fluid therapy and hospital outcomes for vaso-occlusive episodes in children, adolescents, and young adults with sickle cell disease.

BACKGROUND: While intravenous fluid (IVF) therapy in patients with sickle cell disease (SCD) admitted for a vaso-occlusive episode (VOE) can help reduce red blood cell sickling, clinical practice varies across institutions. We examined the relationship between IVF therapy and hospital length of stay (HLOS), as well as adverse events, such as acute chest syndrome (ACS), pediatric intensive care unit (PICU) transfer, and 28-day re-admission. METHODS: This is a single-center retrospective analysis of SCD VOE hospitalizations between January 2015 and April 2020. Patients with SCD, age 0-30, with consecutive hospitalizations for VOE were included. For the first 3 days of each admission, an "IVF ratio" was calculated by dividing actual IVF rate administered by weight-based maintenance IVF (mIVF) rate. RESULTS: A total of 617 hospitalizations for 161 patients were included. Mean HLOS was 5.7 days, (SD 3.9), and mean IVF volume over the first 3 days of admission was 139.6 mL/kg/day (SD 57.8). Multivariate analysis showed that for each additional 0.5 times the mIVF rate, HLOS increased by 0.53 day (p < .001; 95% confidence interval [CI]: 0.609-0.989), but there was no significant association between IVF therapy and adverse events. History of chronic pain was associated with increased odds of re-admission (OR 6.4; 95% CI: 3.93-10.52). CONCLUSIONS: Despite the theoretical potential for IVF therapy to slow down the sickling process, our findings suggest that increased IVF therapy was associated with prolonged HLOS, which places a burden on patients, families, and the health system.

The 2023 Sir David Cuthbertson Lecture. A fluid journey: Experiments that influenced clinical practice.

This review summarises some of my work on fluid and electrolyte balance over the past 25 years and shows how the studies have influenced clinical practice. Missing pieces in the jigsaw are filled in by summarising the work of others. The main theme is the biochemical, physiological and clinical problems caused by inappropriate use of saline solutions including the hyperchloraemic acidosis caused by 0.9% saline. The importance of accurate and near-zero fluid balance in clinical practice is also emphasised. Perioperative fluid and electrolyte therapy has important effects on clinical outcome in a U-shaped dose response fashion, in which excess or deficit progressively increases complications and worsens outcome. Salt and water overload, with weight gain in excess of 2.5 kg worsens surgical outcome, impairs gastrointestinal function and increases the risk of anastomotic dehiscence. Hyperchloraemic acidosis caused by overenthusiastic infusion of 0.9% saline leads to adverse outcomes and dysfunction of many organ systems, especially the kidney. Salt and water deficit causes similar adverse effects as fluid overload at the cellular level and also leads to worse outcomes. Serum albumin is shown to be affected mainly by dilution and inflammation and is not a good nutritional marker. These findings have been incorporated in the British consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients (GIFTASUP) and National Institute for Health and Care Excellence (NICE) guidelines on intravenous fluid therapy in adults in hospital and are helping change clinical practice and improve outcomes.

Impact of a Treatment Guide on Intravenous Fluids in Minimising the Risk of Hospital-Acquired Hyponatraemia in Denmark.

Hypotonic intravenous (IV) fluids are associated with an increased risk of hospital-acquired hyponatraemia, eventually leading to brain injury and death. We evaluated the effectiveness of a treatment guide to improve prescribing practices of IV fluids. We conducted a before-and-after cross-sectional survey among physicians working at Danish emergency departments. The primary outcome was prescribing practices of IV fluids. Participants were asked which IV fluid they would select in four clinical scenarios. We applied multivariate logistic regression models to estimate the odds ratio of selecting hypotonic fluids. Secondary outcomes included knowledge about IV fluids and hyponatraemia, and the receipt, reading, and usefulness of the treatment guide. After the intervention, about a third (47/154) reported that they would use hypotonic fluids in patients with increased intracranial pressure, and a quarter (39/154) would use hypotonic maintenance fluids in children, both of which are against guideline recommendations. A total of 46% selected the correct fluid, a 3% hypertonic saline solution for a patient with hyponatraemia and severe neurological symptoms. None of the knowledge questions met the predefined criteria of success of 80% correct answers. Of the respondents, 22% had received the treatment guide. Since the implementation failed, we recommend improving distribution by applying methods from implementation science.

Bicarbonate-Based Solution for the Management of Established Acute Kidney Injury: A Pilot Open-Label Observation Study.

Background Administration of intravenous (IV) solutions constitutes a key component of acute kidney injury (AKI) management. However, the optimal IV fluid solution in the setting of AKI remains uncertain. In this study, we assessed whether the use of bicarbonate-containing solution in patients with established AKI is associated with early renal recovery as compared to bicarbonate-free solutions. Methods We performed an open-label observational pilot study in 59 patients with established AKI. IV fluid solutions that were used include bicarbonate-based solution with low chloride content (80 mEq/L of 8% sodium bicarbonate in a solution that contains 77 mEq/L of sodium, 77 mEq/L of chloride and 25 g/L of glucose) or solutions without bicarbonate with high chloride content (0.9% normal saline, 0.45% half-saline, normal ringer, or 4% succinylated gelatine). We evaluated the association of IV fluids type with renal recovery. Results The median age of study participants was 66 years (inter-quartile range (IQR) 37-85), and 59% (n=35) were men. The prevalence of diabetes and chronic kidney disease (CKD) stages 1-3 were 34% (n=20) and 39% (n=23), respectively. Patients who received bicarbonate-based IV solutions had a greater reduction of serum creatinine (sCr) per day (delta sCr) as compared with patients who received bicarbonate-free solutions (-0.29±0.47 vs. 0.07±0.42; p=0.007). The renal recovery was faster in patients who received bicarbonate-based solutions as compared to the bicarbonate-free group (days from peak sCr to baseline sCr: 5.6±2.1 vs. 7.6±2.8; p < 0.001, respectively). Conclusions We observed faster renal recovery in patients with established AKI who received the bicarbonate-based solution with low chloride content. Our study findings require confirmation in larger cohorts.

Implementation of the medical emergencies in eating disorders in adults guidance on non-specialist units.

The Royal College of Psychiatrists recently published data showing an 84% increase in UK hospital admissions for eating disorders over the past 5 years, highlighting the importance of the college's new Medical Emergencies in Eating Disorders (MEED) guidance. This includes a 79% increase among adults, many of whom are admitted to general medical wards that do not have input from expert eating disorder services. Consequently, the multidisciplinary nutrition support team, nutrition specialist nurses and dietitians have a potentially vital role in implementing MEED to ensure that the appropriate nutritional, fluid and electrolyte management is in place for safe refeeding and avoidance of the potentially harmful underfeeding syndrome. Furthermore, the guidance includes special recommendations for the use of nasogastric feeding in eating disorder patients, which requires input from experts in this field, including specialist nurses and dietitians. This article focuses on the implementation of MEED on hospital wards that do not have input from specialist eating disorders services.

Emerging concepts in the care of patients with cirrhosis and septic shock.

Septic shock impacts approximately 6% of hospitalized patients with cirrhosis and is associated with high rates of morbidity and mortality. Although a number of landmark clinical trials have paved the way for incremental improvements in the diagnosis and management of septic shock in the general population, patients with cirrhosis have largely been excluded from these studies and critical knowledge gaps continue to impact the care of these individuals. In this review, we discuss nuances in the care of patients with cirrhosis and septic shock using a pathophysiology-based approach. We illustrate that septic shock may be challenging to diagnose in this population in the context of factors such as chronic hypotension, impaired lactate metabolism, and concomitant hepatic encephalopathy. Furthermore, we demonstrate that the application of routine interventions such as intravenous fluids, vasopressors, antibiotics, and steroids should be carefully considered among those with decompensated cirrhosis in light of hemodynamic, metabolic, hormonal, and immunologic disturbances. We propose that future research should include and characterize patients with cirrhosis in a systematic manner, and clinical practice guidelines may need to be refined accordingly.

Midwives' perspectives of intravenous fluid management and fluid balance documentation in labour: A qualitative reflexive thematic analysis study.

AIM: To describe current practice, examine the influences and explore barriers and facilitators to accurate documentation, for the administration of intravenous fluids during labour. DESIGN: A descriptive qualitative study was performed. METHODS: Qualitative semi-structured interviews were conducted with Registered Midwives working across Australia. Midwives were recruited via email and social media advertisements. A maximum variation sampling strategy was used to identify potential participants. Interview questions explored four main areas: (i) understanding of indications for IV fluids in labour; (ii) identification of current practice; (iii) barriers to documentation and (iv) benefits and complications of IV fluid administration. Reflexive thematic analysis of recorded-transcribed interviews was conducted. RESULTS: Eleven midwives were interviewed. Clinical practice variation across Australia was recognized. Midwives reported a potential risk of harm for women and babies and a current lack of evidence, education and clinical guidance contributing to uncertainty around the use of IV fluids in labour. Overall, eight major themes were identified: (i) A variable clinical practice; (ii) Triggers and habits; (iii) Workplace and professional culture; (iv) Foundational knowledge; (v) Perception of risk; (vi) Professional standards and regulations; (vii) The importance of monitoring maternal fluid balance and (viii) barriers and facilitators to fluid balance documentation. CONCLUSION: There was widespread clinical variation identified and midwives reported a potential risk of harm. The major themes identified will inform future quantitative research examining the impact of IV fluids in labour. IMPACT: The implications of this research are important and potentially far-reaching. The administration of IV fluids to women in labour is a common clinical intervention. However, there is limited evidence available to guide practice. This study highlights the need for greater education and evidence examining maternal and neonatal outcomes to provide improved clinical guidance.

Fluids in the ICU: which is the right one?

The administration of fluids is one of the most common interventions in the intensive care unit. The effects and side effects of intravenous fluids depend on the amount administered and their specific composition. Intravenous fluid solutions are either considered crystalloids (for example 0.9% saline, lactated Ringer's solution) or colloids (artificial colloids such as gelatins, and albumin). This narrative review summarizes the physiological principles of fluid therapy and reviews the most important studies on crystalloids, artificial colloids and albumin in the context of critically ill patients.

Development and validation of an audit tool for fluid management in non-critically ill adults in the emergency department.

Especially in the emergency department (ED), it is critical to identify weaknesses in prescribing behavior of IV maintenance fluids to ensure a qualitative 24-h fluid management plan. The primary aim of this study was to develop an audit instrument to assess the pitfalls in documentation and prescribing habits of IV fluid therapy for non-critically ill patients admitted to the ED. In this study, an expert panel initially designed the tool. During different phases, adaptations were made to optimize inter-rater agreement (Fleiss' kappa, κ) and validity was determined based on the application of the tool on randomly selected electronic ED patient records. Second, the IV fluid prescription's appropriateness was addressed. The final tool consists of three parts: fluid status assessment, evaluation of maintenance fluid needs and, if present, a limited appropriateness check of the fluid prescription. A manual enhanced inter-rater agreement. κ-values achieved the target value (0.40) after three adaptation rounds, except for the category of 'clinical observations' in the assessment part (κ = 0.531, 95% CI 0.528-0.534), which was acceptable. A check of the IV fluid's indication and volume was only possible with an additional expert evaluation to conclude on prescription appropriateness. Criterion related validity of the final version was high (93.4%). To conclude, the instrument is considered reliable and can be used in clinical practice to evaluate ED fluid management. Thorough documentation is essential to evaluate the appropriateness of the IV fluid prescription, to improve information transfer on IV fluid therapy to the ward and to facilitate retrospective chart review of ED prescribing behavior.

Comparison of Warming Capabilities Between Buddy Lite, enFlow, and Thermal Angel for US Army Medical Personnel in Austere Conditions: A Literature Review.

US Army Forward Surgical Elements (FSEs) are highly mobile teams that provide damage control surgery (DCS) and damage control resuscitation (DCR) in austere locations that often lack standard hospital utilities (electricity, heat, food, and water). FSEs rely on portable battery-operated intravenous (IV) fluid warmers to remain light and mobile. However, their ability to warm blood in a massive resuscitation requires additional analysis. The purpose of this literature review is to examine the three most common battery-operated IV fluid warmers as determined by type and quantity listed on the Mission Table of Organization and Equipment (MTOE) of organic mobile medical units. These include the Buddy Lite, enFlow, and Thermal Angel, which are available to deployed US Army FSEs for blood resuscitation therapy. Based on limited available evidence, the enFlow produced higher outlet temperatures, effectively warmed greater volumes, reached the time to peak temperature faster, and produced greatest flow rates, with cool saline (5-10°C), compared to the Thermal Angel and Buddy Lite. However, recently the US Food and Drug Administration (FDA) issued a Class 1 recall on enFlow cartridges. Testing demonstrated aluminum elution from enFlow cartridges into IV solutions, thereby exposing patients to potentially unsafe aluminum levels. The authors recommend FSE units conduct a 100% enFlow cartridge inventory and seek an alternative IV fluid warming system prior to enFlow cartridge disposal. If an alternative does not exist, or the alternative warming system does not fit mission requirements, then medical personnel must carefully weigh the risks and benefits associated with the enFlow delivery system.