INTRAVENOUS FLUID THERAPY CLINICAL CARE RECOMMENDATIONS

Transcription

1 INTRAVENOUS FLUID THERAPY CLINICAL CARE RECOMMENDATIONS Clinical Assessment Vital signs n admissin Evaluate hydratin status clinically Mnitring Vital signs per nursing prtcl Dcument intake and utput Onging assessment fr signs f dehydratin Dry muth and tngue Crying withut tears Decreased urine utput Delayed capillary refill Pr skin turgr Weight lss Observe fr clinical signs f hypnatremia Lethargy Irritability Weakness Seizures Fluids, Electrlytes, Nutritin Cnsider enteral fluids befre administering IV fluids IV blus Selectin f Intravenus Fluids Given cncern fr excess ADH secretin, prviding IVF at a vlume greater than maintenance is discuraged. Instead, mnitr fr nging lsses and replace as needed. Advance ral intake and reduce IVF as clinically tlerated Labratry Studies Baseline electrlytes may be cnsidered when starting IVF therapy in hspitalized children. Obtain daily sdium levels in patients at high risk fr ADH secretin receiving maintenance fluids Obtain sdium levels in ther patients receiving prlnged maintenance IVF If serum Na is less than 130 meq/l r greater than150 meq/l, btain repeat electrlytes every 6 hurs until crrected Page 1 f 7

2 TABLE OF CONTENTS Pathway Summary Target Ppulatin Backgrund Definitins Initial Evaluatin see Clinical Assessment Mnitring Therapeutics see Fluids, Electrlytes, Nutritin Labratry Studies Imaging Parent Caregiver Educatin N/A References Clinical Imprvement Team TARGET POPULATION Inclusin Criteria All inpatients except thse listed belw Exclusin Criteria Patients with: Acute kidney injury Chrnic renal failure Hypernatremia Endcrine r renal abnrmalities leading t electrlyte derangements Onclgy treatment prtcl Admissin t NICU BACKGROUND DEFINITIONS Intravenus maintenance fluid therapy cnsists f water and electrlytes t replace daily lsses in ill children in whm enteral fluids are insufficient. Based n the Hlliday Segar frmula, hyptnic fluids have been widely used in pediatrics fr several decades. 1 Hwever, accumulating evidence shws that using hyptnic fluids may lead t an increased risk f hypnatremia. 2,3 Studies have been limited by a significant number f surgical patients and varying intravenus fluid (IVF) regimens including fluids cntaining less than ½ nrmal saline (NS). Besides the use f hyptnic fluids, many hspitalized children are felt t have nn-smtic stimuli fr anti-diuretic secretin (e.g. pstsurgical patients, respiratry infectins, neurlgic disease) which leads t a decrease in free water excretin and may cntribute t hypnatremia. 1 Symptmatic hypnatremia manifests as central nervus system symptms including lethargy, irritability, weakness, seizures, cma, and even death. These clinical care recmmendatins were develped with the aim f decreasing iatrgenic hypnatremia in hspitalized children. Page 2 f 7

3 Definitins Hypnatremia: serum sdium (Na) less than r equal t 135 meq/l Hyptnic fluids: fluids with a lwer smtic pressure than bld (e.g. dextrse 5% in 0.45% sdium chlride [D5 1/2NS], dextrse 5% in 0.225% sdium chlride [D5 ¼ NS]) 3 Istnic fluids: fluids with smtic pressure equal t bld (e.g. dextrse 5% in 0.9% sdium chlride [D5 NS]) CLINICAL ASSESSMENT Vital signs n admissin Evaluate hydratin status clinically MONITORING Vital signs per nursing prtcl Dcument intake and utput Onging assessment fr signs f dehydratin Dry muth and tngue Crying withut tears Decreased urine utput Delayed capillary refill Pr skin turgr Weight lss Observe fr clinical signs f hypnatremia Lethargy Irritability Weakness Seizures FLUIDS, ELECTROLYTES, NUTRITION Cnsider enteral fluids (ral, nasgastric [NG]) befre administering IV fluids NG feeds have been safely used in infants hspitalized with brnchilitis 4 IV blus: initial 20 ml/kg NS r lactated Ringer s (LR) fr rehydratin; repeat as clinically indicated Selectin f Intravenus Fluids Hyptnic Fluids (less than ½ NS) shuld nt be used t prvide rutine fluid maintenance therapy Fr the rare patient with hypernatremic dehydratin, particularly ne with diabetes insipidus r any excess in free water lsses, there is a place fr hyptnic slutins such as D5 ¼ NS r even dextrse 5% in water [D5W], depending n their clinical circumstances and ther lsses Patients wh are cnsidered t be at high-risk f antidiuretic hrmne (ADH) secretin (e.g. pst-surgical patients, respiratry infectins, neurlgic disease), istnic saline (e.g. D5 NS) fr maintenance requirements is recmmended Patients nt at risk f ADH secretin, D5 1/2NS and D5 NS are recmmended Page 3 f 7

4 Current data cannt definitively state there is an increased risk f hypnatremia with ½ NS cmpared t NS. In a small, randmized cntrl trial f nn-surgical, nn-icu hspitalized children, serum Na levels were similar at 24 hurs and 48 hurs in thse receiving D5 NS cmpared t thse receiving D5 ½ NS. 5 Hwever, D5 NS is preferred as there is n reprted increased risk f adverse effects frm using NS. Given cncern fr excess ADH secretin, prviding IVF at a vlume greater than maintenance is discuraged. Instead, mnitr fr nging lsses and replace as needed. Advance ral intake and reduce IVF as clinically tlerated LABORATORY STUDIES IMAGING Baseline electrlytes may be cnsidered when starting IVF therapy in hspitalized children, if this may change management Obtain daily sdium levels in patients at high risk fr ADH secretin receiving maintenance fluids Even patients receiving istnic fluids can develp hypnatremia 2 Obtain sdium levels in ther patients receiving prlnged maintenance IVF If serum Na is less than 130 meq/l r greater than150 meq/l, btain repeat electrlytes every 6 hurs until crrected Page 4 f 7

5 REFERENCES 1. Cavari Y, Pitfield AF, Kissn N. Intravenus maintenance fluids revisited. Pediatr Emerg Care 2013;29:1225-8; quiz Carandang F, Anglemyer A, Lnghurst CA, et al. Assciatin between maintenance fluid tnicity and hspitalacquired hypnatremia. J Pediatr 2013;163: Wang J, Xu E, Xia Y. Istnic versus hyptnic maintenance IV fluids in hspitalized children: a meta-analysis. Pediatrics 2014;133: Kugelman A, Raibin K, Dabbah H, et al. Intravenus fluids versus gastric-tube feeding in hspitalized infants with viral brnchilitis: a randmized, prspective pilt study. J Pediatr 2013;162:640-2 e1. 5. Freidman J BC, DeGrt J, et al. Maintenance Intravenus Fluid in Hspitalized Children: A Randmized, Duble Blind, Cntrlled Trial f 0.9% NaCl/Dextrse 5% vs. 0.45% NaCl/Dextrse 5%. In: Pediatric Academic Scieties Annual meeting; 2013; Washingtn DC; Page 5 f 7

6 CLINICAL IMPROVEMENT TEAM MEMBERS Jenny Reese, MD Hspitalist Medicine Alisn Brent, MD Emergency Medicine Mike DiStefan, MD Emergency Medicine Duglas Frd, MD Nephrlgy Ada Kch, PharmD Clinical Pharmacist Christina. Olsn, MD Hspitalist Medicine Barry Seltz, MD Hspitalist Medicine Kaitlin Widmer, MD Hspitalist Medicine Karen Wilsn, MD Hspitalist Medicine Denise Pickard, RN, MSN Clinical Care Guideline Crdinatr APPROVED BY Pharmacy and Therapeutics Cmmittee - August 2014 Apprved by: The Children s Hspital Clrad Guideline Review Cmmittee - August 2014 MANUAL/DEPARTMENT ORIGINATION DATE Clinical Care Guidelines/Quality Nvember 20, 2014 LAST DATE OF REVIEW OR REVISION Nvember 20, 2014 APPROVED BY Daniel Hyman, MD, MMM, Chief Quality Officer, Children s Hspital Clrad REVIEW/REVISION SCHEDULE Scheduled fr full review n Nvember 20, 2018 Clinical pathways are intended fr infrmatinal purpses nly. They are current at the date f publicatin and are reviewed n a regular basis t align with the best available evidence. Sme infrmatin and links may nt be available t external viewers. External viewers are encuraged t cnsult ther available surces if needed t cnfirm and supplement the cntent presented in the clinical pathways. Clinical pathways are nt intended t take the place f a physician s r ther health care prvider s advice, and is nt intended t diagnse, treat, cure r prevent any disease r ther medical cnditin. The infrmatin shuld nt be used in place f a visit, call, cnsultatin r advice f a physician r ther health care prvider. Furthermre, the infrmatin is prvided fr use slely at yur wn risk. CHCO accepts n liability fr the cntent, r fr the cnsequences f any actins taken n the basis f the infrmatin prvided. The infrmatin prvided t yu and the actins taken theref are prvided n an as is basis withut any warranty f any kind, express r implied, frm CHCO. CHCO declares n affiliatin, spnsrship, nr any partnerships with any listed rganizatin, r its respective directrs, fficers, emplyees, agents, cntractrs, affiliates, and representatives. Page 6 f 7

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