Improving peri-operative fluid management in a large teaching hospital: pragmatic studies on the effects of changing practice

Abstract

Concerns about the over-prescription of peri-operative fluids, particularly normal saline, culminated in the recent publication of UK national guidelines on fluid prescription during and after surgery. A working group comprising members of the nutrition support team, surgeons, anaesthetists and pharmacists therefore sought to reduce the overall levels of fluid prescription and to limit normal saline usage in our large Teaching Hospital by producing written local fluid prescribing guidelines and holding a series of fluid prescription education sessions for consultants and junior staff. Ideally, the success of such measures would have been determined by studies on fluid balance, body weight and/or measured body water in large numbers of individual patients in a large cluster-randomised controlled trial. However, this would have proved logistically difficult and very costly especially as it is notoriously difficult to rely on the accuracy of daily fluid balance charts in large numbers of patients on busy post-operative surgical wards. We therefore undertook a pragmatic study, comparing historical data on fluid type/volume prescribed (from both individual and ward level pharmacy records), The UK Reference Nutrient Intake for sodium (Na) suitable for maintenance in normal adults is 70 mmol/24 h, which should be accompanied by about 1 . 5-2 . 5 litres Abbreviations: IV, intravenous; MEWS, medical early warning score; OD, oedematous.

Undergraduate medical textbooks do not provide adequate information on intravenous fluid therapy: a systematic survey and suggestions for improvement

“…The British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients (GIFTASUP) recommend appropriate IV fluid prescribing in the pre-operative and postoperative period. Recent prospective surveys, using historical controls, suggested that guidelines and instruction on fluid management could improve outcome [9,18]. Teaching on these important clinical skills should use uniform guidance to avoid inconsistencies, and ideally in clinical surroundings with practical experience, such as “pre-prescribing” [19].…”

Perioperative intravenous fluid prescribing: a multi-centre audit

“…The balanced crystalloid solutions were the most common postoperative fluid, with hypotonic crystalloids (dextrose-saline solutions) and 0.9 % sodium chloride as the next most common. There is increasing recognition that the traditional postoperative regime of 0.9 % sodium chloride and 5 % dextrose risks sodium, chloride and salt overload (De Silva et al 2010 ). Sodium chloride (0.9 %), even when not given in excessive quantities, is associated with a variety of detrimental effects such as hyperchloraemic acidosis, reduced renal blood flow, increased chance of renal failure and increased in-hospital mortality after major abdominal surgery (Lobo 2012 ).…”

“…Sodium chloride (0.9 %), even when not given in excessive quantities, is associated with a variety of detrimental effects such as hyperchloraemic acidosis, reduced renal blood flow, increased chance of renal failure and increased in-hospital mortality after major abdominal surgery (Lobo 2012 ). Data from Wessex in 2007 found that over 70 % of postoperative fluid prescriptions were 0.9 % sodium chloride or 5 % dextrose (De Silva et al 2010 ). This figure was reduced to 40 % in 2009 after a targeted education intervention (De Silva et al 2010 ).…”

“…Data from Wessex in 2007 found that over 70 % of postoperative fluid prescriptions were 0.9 % sodium chloride or 5 % dextrose (De Silva et al 2010 ). This figure was reduced to 40 % in 2009 after a targeted education intervention (De Silva et al 2010 ). It appears that this downward trend has continued as evidenced by our work.…”

“…Education of junior doctors can make an impact on their prescribing choices (De Silva et al 2010 ) but there is always a risk that any relatively short lived intervention only lasts a limited period of time before traditional practice starts to re-establish itself. The variation in intraoperative fluid volumes observed in theatre means that there is a quality improvement work that might be required in this environment as well.…”