TABLE 1
Junior doctor questionnaire responses
How confident are you when dealing with fluid prescribing ? Scored 1 ( not very ) to 5 ( very )
Do you feel like you have received adequate training on fluid prescribing as an undergraduate ?
Do you feel like you have received adequate training on fluid prescribing in work ?
Do you think that a teaching session on fluid prescribing would be helpful ?
Have you heard of Maintelyte ® for routine maintenance fluids ?
Have you seen the ELHT Fluid Stewardship educational films on the intranet ?
3.8
3.2
2.6
3.4
60 %
0 %
The fluid stewardship induction session for new foundation year doctors will help , but we have two other developments in the pipeline for 2021 that should make it easier for prescribers to perform a safe and effective job when prescribing fluids .
New fluid prescription chart The Trust is about to introduce a new paper prescription chart ( a 12-page booklet ) ahead of electronic prescribing in late 2022 . The fluid section has been extensively revised to support our fluid stewardship programme , and now appears as a gatefold section with printed reminders of how to prescribe fluids for different indications ( Figure 5 ), with a separate section for resuscitation fluid , and checkboxes to show the other fluid indication ( s ) ( Figure 6 ).
Blippit Meds app The concept of using a smartphone application to help prescribers choose the right fluid and the right dose volume came out of conversations with the Fluid Stewardship Committee . Anyone watching our educational films , viewing the key points on the intranet , and supported by the new prescription chart should have the empirical knowledge to prescribe fluids effectively ; however , we really wanted to make it easy to do an effective job .
The critical care team had been using an app that we had devised a few months earlier – Blippit Meds . This was originally designed to help nurses quickly view injectable drugs ’ monographs in the treatment rooms without having to rely on paper copies or computers ; they could access them on their smartphones . We approached our app developer to see if a fluid decision aid could be made that followed the principles of the NICE CG174 prescribing algorithm , and with some simple choices and inputs , for example , a patient ’ s weight , could show the right fluid choice and volume for a given clinical situation . It turns out this was possible , and at the time of writing the final
Key points
• Forming the Fluid Stewardship Committee led to a deeper understanding of the issues surrounding intravenous fluid management .
• Empirical evaluation and audit revealed mismatch in prescribers ’ beliefs and their prescriptions .
• Prescription charts were redesigned to support educational programme .
• Blippit Meds app innovated to create a fluid prescribing decision tool .
• Pharmacists are well placed to be effective ‘ fluid stewards ’.
FIGURE 5
Guidance notes on ELHT fluid section of new prescription chart
Intravenous fluid therapy guidance ( see ‘ fluid stewardship ’ guidance on intranet under ‘ clinical information for full details ) w
1 Assess or reassess patient
Hypovolaemic ( reassess regularly ) |
Euvolaemic |
Special cases : consult a |
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senior doctor or refer to |
|
|
guidelines |
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2 Determine the indication for a fluid
3 What volume ? Consider :
• patient ’ s history
• weight
• U & Es
• fluid balance other fluid intake , e . g ., IV antibiotics
|
Resuscitation
Fluid challege : 500ml ( or 250ml ) at a rate of 1200ml / hour and then reassess Use 250ml if patient has CKD , CCF , or bodyweight < 50kg
|
Replacement and redistribution
Estimate losses in previous 24 hours and any ongoing needs due to redistribution
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Routine maintenance
5ml / kg / 24hrs If patient has CKD , CCF or is frail , use 20ml / kg / 24hrs Remember to subtract any other intake Total fluid needs =......... ml ( round to nearest 100ml or a maximum of 2400ml ) Maximum rate is 100ml / hour or 1000ml / 10 hours
|
• Cardiac dysfunction
• Liver dysfunction
• Renal dysfunction
• Head injury
• Post-operative ERP
• Obstetrics
• DKS / HHS If using variable rate insulin infusion ( VRII ) protocol the prescribe fluids as per VRII prescription chart .
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4 Which fluid to use ? Use the Trust ’ s ‘ Blippit Meds ’ app to help with fluid choice and volume ( consult iwth ward pharmacist for more information ) |
Plasma-Lyte 148 ®
• Use blood products if bleeding
Contact the acute care team if you require further advice
|
Plasma-Lyte 148 ®
• Use sodium chloride 0.9 % + potassium ( 20-40mmol / l ) for upper GI loss
• If potassium > 5 mmol / l use sodium chloride 0.9 %
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Maintelyte ® ( contains k + 20mmol / l ) Prescribe maintenance fluid for the next 24 hours during the ward round , ideally during waking hours .
• If potassium > 5mmol / l use sodium chloride 0.18 % + glucose 4 %
• If sodium < 133mmol / l ascertain cause , follow Hyponatraemia guideline or consult acute care team
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hospitalpharmacyeurope . com | 2021 | Issue 99 | 19