Brief summary of the NICE guidelines December 2013

Transcription

1 Brief summary of the NICE guidelines December 2013 Intravenous fluid therapy in adults in hospital the relevance to Emergency Department Care Applicable to patients 16 years and older receiving i.v. fluids without the following exceptions Pregnant women Severe liver or renal disease Diabetes Burns Patients requiring ionotropes Those on intensive monitoring Traumatic brain injury patients This guideline centres around the 5Rs Resuscitation Routine maintainance Replacement Redistribution Reassessment Key background As many as 1 in 5 patients on i.v fluids and electrolytes suffer complications or morbidity due to their inappropriate administration Considerable debate as to the best i.v. fluids to use resulting in a variation in clinical practice this mainly stems from the difficulties in interpreting the evidence Assessment Assessment should be focused on the following areas Likely electrolyte needs from their history o Intake/thirst o Quantity and composition of losses o Comorbidities including malnourishment (at risk of refeeding syndrome) Clinical examination o pulse, BP, cap refill and JVP o presence of pulmonary/peripheral oedema o presence of postural hypotension

2 Indicators of a patient requiring urgent fluid resuscitation Systolic BP < 100mmHg Pulse rate > 90 BPM Capillary refill > 2 seconds Peripheries are cold to touch Respiratory rate > 20 breaths per minute National Early Warning Score (NEWS) 5 Passive leg raising suggests fluid responsiveness Clinical monitoring o National early warning score o Fluid balance charts o Weight Current medications Laboratory investigations, should include trends in o FBC o U+Es, creatinine and electrolytes Patients receiving i.v. fluids for resuscitation require reassessment using the ABCDE approach whilst monitoring their respiratory rate, pulse, blood pressure and perfusion continuously and measure venous lactate and/or arterial ph and base excess Patients should all have an i.v. fluid management plan including Fluid and electrolyte prescription over the next 24 hrs The assessment and monitoring plan NB- it may not be practical in ED patients to anticipate exact requirements for the next 24hrs, however every effort must be made to ensure that appropriate fluids are prescribed for an appropriate timeframe until the receiving specialty will be able to see the patient. Note also that the guideline states; if patients are transferred to a different location, reassess their fluid status and i.v. fluid management plan on arrival in the new setting Monitoring All patients receiving i.v. fluid therapy need regular monitoring. Initially at least daily reassessments of; Clinical fluid status Laboratory values (urea, creatinine and electrolytes) Fluid balance charts In addition to twice weekly weight measurements

3 Resuscitation Patients receiving i.v. fluid resuscitation should receive 500 ml volumes of crystalloids (containing sodium in the range of mmol/l) over less than 15 minutes From an ED point of view that includes 0.9% Sodium chloride Hartmann s Plasma These boluses can be repeated to a volume of 2 litres in an attempt to meet their resuscitation needs. If unsuccessful by 2 litres escalation to expert help, i.e. critical care, is warranted Of note Do not use tetrastarch for fluid resuscitation Consider human albumin solution 4-5% for fluid resuscitation only in patients with severe sepsis Routine maintainance If a patient needs i.v. fluids for routine maintainance alone, restrict the initial prescription to ml/kg/day of water and o approximately 1mmol/kg/day of potassium o approximately g/day of glucose to limit starvation ketosis NB for obese patients their i.v. fluid prescription should be matched to their ideal body weight, therefore patients rarely need more than 3 litres of fluid per day Replacement and Redistribution Adjust the i.v. prescription to account for existing fluid/electrolyte deficits or excesses, ongoing losses or abnormal distribution e.g gross oedema

4 Adverse Events Incidents of fluid mismanagement (e.g. prolonged dehydration or inadvertent fluid overload due to i.v. therapy) should be reported through standard clinical incident reporting pathways Key points for ED A thorough assessment of needs is required including history, examination, laboratory testing where appropriate and reassessment Resuscitation should be carried out normally with Hartmann s or 0.9% Saline in 500 ml boluses over a maximum of 15 minutes Once 2000 ml of fluid has been used in the resuscitation then input from critical care should be sought Every effort must be made to prescribe maintenance fluids required for patients in the Emergency Department until such time that they will be reviewed by the admitting specialty Obese patients should have fluid prescriptions directed towards their ideal body weight Adverse events should be taken seriously and reported as part of governance and ongoing education NICE i.v. fluid algorithm available at

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