Index No: MMG11/1. Version: 1. Date ratified: 12 th November 2013

Transcription

1 Index No: Intravenous fluid prescription in children For previously well children aged one month to 16 years (excluding renal, cardiac, diabetic ketoacidosis and acute burns patients) Version: 1 Date ratified: 12 th November 2013 Ratified by: (Name of Committee) Name of originator/author, job title and department: Director Lead (Trust-wide policies) Associate Medical Director (local Policies) Clinical Management Team / Directorate Applicable to Name of responsible committee for the policy: Date issued for publication: July 2013 Quality Governance Committee Dr H Bilolikar, Associate Medical Director, Women & Children CMT and Dr K Kallambella (ST4 paediatrics) Women & Children CMT Medical Director Women & Children CMT Review date: August 2016 Medicines Management Committee Expiry date: (Date 3 months following review date) Equality impact assessed by: (name, job title and department) Date impact assessed: November 2016 This clinical guideline does not involve direct engagement with staff, patients, carers, visitors, the public or others and therefore does not require an Impact Assessment in line with procedure D10a NA Registration Requirements Outcome Outcome 9 Number(s) (CQC) NHSLA standard 5.10 CNST standard N/A

2 CONTRIBUTION LIST Individuals involved in developing the document Name Dr H Bilolikar Dr K Kallambella S Hussain Designation Associate Medical Director, Womens and Childrens CMT Deputy Chief Pharmacist Circulated to the following individuals for consultation Name Dr C Royed Dr Acharya Dr Margabanthu Designation Consultant paediatrician Consultant paediatrician Consultant paediatrician

3 Index No. Approval and Authorisation Completion of the following signature blocks signifies the review and approval of this process. Name Job Title Signature Date Local Committee approval (where applicable) Name of Committee Paediatric Guidelines Committee Name of Date of Approval Chairperson Dr Bilolikar 12/06/2013 Change History Version Date Author Reason Impact Assessment This clinical guideline does not involve direct engagement with staff, patients, carers, visitors, the public or others and therefore does not require an Impact Assessment in line with Procedure D10a A translation service is available for this policy. The Interpretation/Translation Policy, Guidance for Staff (I55) is located on the library intranet under Trust wide policies.

4 CONTENTS PAGE 1.0 INTRODUCTION 2.0 DOCUMENT CONTENT Calculating the fluid volume required Choosing the fluid Monitoring the patient 3.0 MONITORING COMPLIANCE AND EFFECTIVENESS 4.0 PROCESS FOR IMPLEMENTATION AND DISSEMINATION 5.0 DOCUMENT REVIEWS AND UPDATES 6.0 REFERENCES APPENDIX 1 Algorithm for intravenous fluid prescription in children INTRODUCTION

5 In March 2007, the National Patient Safety Agency (NPSA) issued advice to healthcare organisations on how to minimise the risks associated with administering infusions to children. This advice is in response to 4 recorded deaths (and 1 near miss) following neurological injury from hospital acquired hyponatraemia in the UK between 2000 and The advice (NPSA alert 22) includes a recommendation for the production and dissemination of clinical guidelines for the fluid management of paediatric patients. T CONTENT Calculating the fluid volume required Choosing the fluid Monitoring the patient Correcting for any fluid defecit Algorithm for intravenous prescription in children CALCULATING THE FLUID VOLUME REQUIRED Maintenance Fluid Requirement: based on weight in kg 0-10 kg 100 ml/kg/day kg 1000 ml plus 50 ml/kg/day for weight each kg above 10 kg Above 20 kg 1500 ml plus 20 ml/kg/day for weight each kg above 20 kg up to a maximum of 2000 ml/day in females and 2500 ml/day in males. Calculate the daily requirement as above and divide it by 24 to run it as mls/hour. An example is given below. In addition, if there are on-going losses they should be replaced every 4 hours. Please see below ongoing fluid loss eg For a child who weighs 13 kg: For the First 10 kg =1000 ml Next 3 kg = 3 x50 = 150ml Total = 1150 ml Fluid rate: 1150/24 = 47.9 ml/hr approx. to 47 ml/hr eg For a child weighing 26 kg For the first 20 kg = 1500ml Next 6 kg = 6 x 20 = 120 ml Total = 1620 ml

6 Fluid rate: 1620/24 = 67.5 ml/hr approx. to 67 ml/hr Restricted Maintenance Fluid Requirement Consider restricting the maintenance fluid volume to 2/3rd of normal in certain conditions such as respiratory infections, CNS infections, head injury, seizures, pain, anxiety, and post operative state. Changes in weight, plasma electrolyte levels, and fluid balance [input/output] can further assist in deciding fluid restriction. CHOOSING THE FLUID Resuscitation: Use 0.9% Sodium Chloride ml as bolus if there is evidence of shock and follow resuscitation guidelines. Maintenance: The majority of children may be safely administered Sodium Chloride 0.45% with glucose 5%. Consider using 500ml bags with 10 or 20mmol Potassium Chloride once passing urine and potassium level is known. Do not prescribe 0.18% Sodium Chloride with 5% glucose or plain 5% dextrose or 10% dextrose solutions. Use 0.9 % Sodium Chloride with 5% Glucose in the following conditions where hyponatraemia is more likely. - Bronchiolitis - Sepsis - Head injury - Peri and post operative patients - CNS infection - Excessive Gastro-intestinal losses - Serum sodium less than Serum sodium more than 160 [Seek senior advice] - Intravascular volume depletion - Conditions requiring replacement of on-going losses - Chronic conditions such as CF, Diabetes, pituitary deficits - Salt wasting syndromes Ongoing fluid loss: Intravenous fluids used to replace ongoing fluid losses should reflect the electrolyte composition of the fluid being lost. In most cases 0.9% Sodium Chloride should be used. If required, use 500ml bags with Potassium Chloride 10 or 20mmol. Replace losses every 4 hours and monitor frequently.

7 MONITORING THE PATIENT U&E should be checked daily when a child is on intravenous fluids. More frequent monitoring may be needed in the presence of abnormal electrolyte levels. Check 4-6 hourly if sodium concentration is below 130mmol/L. CORRECTING FOR FLUID DEFICIT Assess for any fluid deficit as percentage body weight in kg. If present, replace as 0.9% Sodium Chloride with glucose 5% or 0.9% Sodium Chloride over a minimum of 24 hours. In that instance, total fluid [deficit+ maintenance] should be prescribed as isotonic i.e. 0.9% Sodium Chloride with 5% glucose. Deficit correction: % dehydration x weight in kg x 10 = total deficit in ml. eg A child weighing 12 kg who has 5% dehydration Deficit is 12 x 50 = 600 ml Daily Maintenance is x 2 = 1100 ml Total fluids = = 1700 ml Rate of infusion should be 1700/ 24 hours = 70.8 ml/hr approx. 70 ml/hr of 0.9% Sodium Chloride with 5% Glucose. MONITORING ARRANGEMENTS FOR COMPLIANCE AND EFFECTIVENESS Pharmacy will monitor the use of 0.18% Sodium Chloride with Glucose 5% in paediatrics annually and report to the Pharmacy Quality Governance Committee. PLAN FOR DISSEMINATION AND IMPLEMENTATION Through paediatric divisional meeting. Guideline to be uploaded onto the intranet by pharmacy. REFERENCES Ref: Reducing the risk of hyponatraemia when administering intravenous infusions to children - Patient Safety Alert V1 Algorithm for intravenous fluid prescription in children For previously well children aged one month to 16 years (excluding renal, cardiac, diabetic ketoacidosis and acute burns patients)

8 Is the patient in shock? Yes No Is there a deficit? Resuscitation fluid ml/kg 0.9% Sodium Chloride followed by deficit correction and maintenance requirement Yes No Assess deficit and correct over 24 hours with 0.9% Sodium Chloride with 5% glucose + Calculate maintenance fluid and add to deficit to give 24 hour requirement Maintenance fluid ie 0.45% Sodium Chloride with 5 % glucose or 0.9% Sodium Chloride with 5% glucose Monitor U&E at least once daily Replace ongoing losses every 4 hours Monitor urine output, fluid input/output and consider weight loss/gain