Reducing Risks:. A New Protocol for the Fluid Management Reducing Risks: A New Protocol for the Fluid Management of Paediatric Diabetic Ketoacidosis (DKA) Jacqueline Wilkinson Aseptic Services Pharmacist Wrexham Maelor Hospital jacqueline.wilkinson@new-tr.wales.nhs.uk

Aims of presentation Explain Background New protocol Problems identified that prompted us to review practice New protocol How it works Benefits to patients Risk reduction Reducing delays in treatment More optimised provision of rehydration fluid

Summary of problem DKA is a medical emergency Management of paediatric DKA is complex, involving several infusions of varying concentrations of glucose and saline, plus potassium and insulin. Requirements are determined by a multistage calculation process and change rapidly, in line with a fast changing biochemical picture. Speed is essential Risks of delay and error are high.

Resuscitation (normal saline) Insulin Rehydration Treatment aims Resuscitation (normal saline) Given immediately on admission Insulin (continuous intravenous infusion) Rehydration Replace volume and electrolytes Here is where difficulties encountered in obtaining required fluids Focus of protocol

Fluid volumes- rehydration fluid Accurate calculation of fluid requirements important in children Over zealous rehydration risks cerebral oedema Rehydrate over a 48 hour period This amount is calculated at admission Complex multistage calculations which take into consideration: Body weight Maintenance fluid appropriate for weight State of hydration This is estimated and quantified by assessment of clinical features when the patient is admitted Minus the resuscitation fluid Components of the fluid are decided by other factors Biochemistry Volume per hour remains the same over the 48 hour period COMPONENTS CHANGE IN RESPONSE TO CLINICAL PICTURE 3 hourly bloods

Problems Rehydration fluid required often not available commercially Particular problem with potassium containing fluids Prepared either on an adhoc basis in our aseptic unit during working hours when capacity available urgent, unpredictable requests for various formulations or on the ward out of hours

2. Delays in treatment incurred due to Preparation of potassium containing fluids on wards associated with two main problems: 1. Risk (Subject of NPSA guidance) Avoidance of use of conc. KCl ampoules Avoidance of preparation of IV infusions of wards Calculation/contamination risks 2. Delays in treatment incurred due to Difficulty with availability/ sourcing required fluids within time restraints Rapidly changing requirements Bloods done three hourly initially

Problems Can we resolve the problem by increasing the stock? Range of potentially required fluids to meet all needs was vast Potassium Some evidence to suggest prescribing/guidance often suboptimal Based on what was available commercially rather than what was required clinically.

Rationalisation

Aims of protocol (4) 1. To optimise adherence to current NPSA guidance and best-evidenced DKA practice 2. To formulate a range of infusions which would remove the need to prepare any product on the ward and therefore reduce risks associated with the practice

Aims (continued) 3. To facilitate easy, minimum-risk prescribing 4. To facilitate variation within defined limits of fluid volume glucose concentration electrolytes Insulin which could be administered to the whole spectrum of paediatric patients, using the minimum of infusion container changes

Method We conceived a new approach Co-administration of an in-house pharmacy prepared potassium infusion, together with the appropriate crystalloid infusion. Each infusion would be independent and the rate of each could be varied to achieve a very wide range of concentrations of glucose and electrolytes. Potassium- standard concentration, variable rate (within limits) Crystalloid- variable concentrations, variable rates We also designed support documentation A series of tables Prescription chart specific to the protocol

The new protocol 500ml bags of crystalloid to be infused at variable rates dependent upon weight and state of dehydration Available as stock will be: Sodium chloride 0.9% 500ml Sodium chloride 0.9% / glucose 5% 500ml Sodium chloride 0.9% / glucose 10% 500ml Sodium chloride 0.45% / glucose 5% 500ml Sodium chloride 0.45% / glucose 10% 500ml Pre-filled syringes of potassium chloride 0.4mmol/ml to be infused at either 0.15mmol/kg per hour or 0.25mmol/kg/hour 0.3mmol/kg/hour Soluble Insulin in prefilled syringes 50units in 50ml

Nominated locked fridge on HDU on childrens ward Restricted access May only be used for patients with PDKA

Benefits Reduces potential for error and delays by eliminating need to make up infusion on ward. 1. Reduces delays in treatment (by reducing delays encountered by difficulties obtaining stock e.g., from ITU or from on call pharmacist). 2. Enables wide ranging flexibility from a small range of easily stocked products 3. Provides user friendly standardised calculation algorithm 4. Enables standardised prescribing

Example Column A Initial Rehydration with moderate potassium supplementation 0.15mmol/kg/hour Potassium chloride pre-filled syringe 0.4mmol/ ml Crystalloid hydration fluid ml/hour 1 2 3 4 5 Wt (kg) ml/hour 3% dehydrated 5% dehydrated 7.5% dehydrated 10% dehydrated 22 8.3 60.5 69.7 81.1 92.6 24 9.0 61.8 71.8 84.3 96.8 26 9.8 63.2 74.0 87.5 101.1 28 10.5 64.5 76.2 90.8 105.3

Risk Management: Potassium prescribing and administration Potassium must be co-infused with crystalloid. Serious error if directly infused into patient Maximum of 10mmol per syringe To avoid gross over infusion Prescribing Use pre-printed prescription Doctor may only prescribe 3 hours worth of potassium at a time After this time, nurses may not continue to infuse potassium if it is not prescribed Serum potassium must be recorded

Training Nurses Doctors Pharmacists Protocol developed with Consultants/registrars Charge nurse Paediatric pharmacists

Results The writing of the protocol, development of supporting products and training of relevant staff was completed in February 2007 and was first used in March 2007 Used in a small number of patients Next stage  Audit Incorporation with ICP

Conclusion We believe that the development of this new protocol has improved our management of paediatric patients who are admitted with DKA by: Reducing risks associated with calculation errors and ward preparation of potassium infusions Entirely eliminating delays in sourcing required infusions Providing a standardised yet very flexible, straight forward protocol for their management

Thank you Any questions?