The National Institute for Health and Care Excellence (NICE) has recently issued new guidance on the use of intravenous fluids in adult patients.
For those clinicians not familiar with it, NICE is the UK-based body that provides guidance by supporting healthcare professionals and others to make sure that the care they provide is of the best possible quality and offers the best value for money. Its recommendations are based on systematic reviews, explicit consideration of cost effectiveness and where evidence is missing, expert opinion.
“Why is there a need to issue guidance on this?” I first thought when I came across this. “After all, we are experts in prescribing and utilising IV fluids in acute setting. We have been doing it for so long!”.
I remember having the same thoughts when the British Thoracic Society issued its framework for the prescription and use of oxygen. Having read the document, I rapidly changed my mind at the time. I did the same with this one!
Despite the fact that fluid management is one of the commonest medical tasks, there has been emerging evidence that emergency and acute care physicians are failing on use of optimal volume, rate or choice of the type of fluid to be administered. This article published in the New England Journal of Medicine looked at the paediatric population and suggests indeed that we had been well overgenerous with fluid volumes during resuscitative phases.
The size of the problem:
The National Confidential Enquiry into Perioperative Deaths (NCEPOD) suggested that as many as 1 in 5 patients receiving IV fluids in hospital suffered complications due to inappropriate administration. The same professional body demonstrated an increased risk of death within thirty days of having a surgical intervention following inappropriate fluid administration. The numbers are not small and seem to be linked to acute care and the guideline is therefore relevant to Emergency Medicine in many aspects.
What are the recommendations?
1. IV fluid therapy is to be provided only to those patients whose needs cannot be met by oral or enteral routes. This seems obvious but we have to acknowledge that we tend to be overzealous with fluid therapy in clinical situations where often a pint of fluid is enough.
2. Prescribing staff need to remember the five Rs: resuscitation, routine maintenance, replacement, redistribution and reassessment. This should be seen as a treatment continuum with each stage having its particularity on fluid type, volume, rate etc.
3. An algorithm is offered to facilitate administration of fluid therapy. Algorithm 1 and 2 are probably the most relevant to Emergency Medicine (assess needs and fluid resuscitation)
4. The guidance further stresses that the type of fluid and rate/volume is to be specified. Now, I am quite bad at this often just scribbling down NaCl STAT (instead of Normal Saline Solution 0.9% at 500ml/h).
5. IV fluid management is to review over the next 24 hours and on a daily basis. This again sounds obvious but there is a need to adjust type, volume and rate according to responsiveness and electrolytes.
6. Take into account all other sources of fluid and electrolytes intake including drugs, IV nutrition, blood and blood products. And yes, it does include that 250ml of Dextrose in which you had given vitamin B complex or the IV paracetamol. Again, I am bad at this!
7. Involve the patient whenever possible in decision making and discuss signs and symptoms to look out for if need is to adjust their balance. I guess, it is a medial intervention so it would be part of the GMC document Good Medical Practice.
What about fluid resuscitation?
1. For acute replacement, the document recommends the use of crystalloids that contain sodium in the range 130 – 154mmol/L with boluses of 500mL over less than 15 minutes. Again, note that the traditional teaching of 20ml/kg would overestimate the volume to be given.
2. Do not use tetrastarch for fluid resuscitation but consider rather human albumin solution 4 – 5% for patients in severe sepsis. This recommendation is based on results from large randomised clinical trials that have reported an increased risk of renal dysfunction and mortality in critically ill or septic patients who received hydroxyethyl starch (HES) compared with crystalloids. It was therefore deemed that the risks of HES products for plasma volume expansion outweigh the benefits in all patient groups and clinical settings and the MHRA recently suspended the licences for all HES products.
3. When using IV fluids containing chloride concentrations >120mml/L (such as our beloved “Normal” Saline solution), monitor serum chloride concentration daily to look out for hyperchloraemic acidosis. Who had not been caught up in this before?
What are the issues around fluid therapy?
Despite being a key area of patient care, it appears according to this document, that most of hospital staff have not received adequate training in assessing the needs and managing fluid and electrolyte therapy.
I think this is probably a fact and I cannot remember when was the last time I read up about the topic (probably around my exit exam period!). The guidance does suggest that hospitals should ensure regular training for staff in order to demonstrate competence in understanding basic physiology, assessing the needs and risks of patients, monitoring response and preventing/treating consequences of mismanaged IV fluid therapy.
As an emergency physician, I find documents like this interesting. Within healthcare systems they have tremendous power and authority, but in trying to cover a topic as vast as fluid replacement they lack the finesse and detail that I deliver on a daily basis in the resuscitation room. If we take a common EM condition such as sepsis then my practice is to make detailed fluid assessments according to physiological data and response to fluids. The NICE guidelines delivers a much more blunt tool, as an example the suggestion to deliver 2000mL of crystalloid for patients before seeking expert help is not the way we deliver critical care in the ED.
In summary, there is some good stuff in the document. The underlying principles are good but as with many national guidelines the tools to deliver lack the finesse and elegance required for the critically ill patient in resus. Emergency physicians will need to look beyond these guidelines if they are to consider themselves resuscitationists.