1. Maintenance Fluid Prescription
Safe intravenous fluid prescription and administration in hospitalised adult patients: where do we stand?
Buttigieg J1, Callus R1, Delicata L1, Bugeja M1, Debono R1,
Bartolo K2, Almuqamam M2, Ghani H2, Santucci S2
1Division of Nephrology, 2Department of Medicine
Background
Results
There were a total of 106 questionnaire respondents.
58% were females.
Foundation doctors 77%; Basic specialist trainees 23%.
Fluid management should be accorded the same status as drug prescription.
Inadequate fluid prescription (FP) has been associated with significant morbidity and mortality1.
Various international guidelines are already in place to ensure appropriate and safe prescription of fluid and electrolyte treatment for in-patients2,3.
Table 2: Questionnaire responses
Question
Yes No
Adequately confident in FP
43%
57%
FP adequately covered in medical school
12%
88%
Check weight prior to FP 6%
93%
Check fluid status prior to FP
66%
34%
Check electrolytes prior to FP
58%
42%
Check intake/output charts prior to FP
65%
41%
Assess FP daily while on maintenance
62%
44%
Na+ concentration in 0.9% saline
46%
54%
Na+ concentration in 0.45% saline
69%
31%
Na+ concentration in Hartmann’s solution
51%
49%
K+ concentration in Hartmann’s solution
50%
Ions in Hartmann’s solution
Na+ concentration in Gelafusine® 7%
Recommended daily maintenance volume
Recommended daily maintenance Na+
18%
82%
Recommended daily maintenance K+
38%
Daily insensible losses
25%
75%
Aim
To audit FP practises in an adult in-patient cohort at Mater Dei Hospital.
To evaluate FP knowledge amongst junior/middle grade doctors.
Method
FP appropriateness was analysed through patient case notes examination.
Patients on an intravenous infusion were selected randomly from medical and surgical wards.
Patients with acute renal failure, those needing glucose/insulin infusions and patients on parenteral feeding were excluded.
Subsequently, essential FP knowledge was evaluated via an anonymous questionnaire distributed amongst junior/middle grade doctors.
Results
A total of 32 case notes were studied, equating to 70 maintenance-fluid-days and 10 resuscitation-fluid-days.
Median age was 38 (range 16-89); 50% were males.
During the maintenance fluid days 40% (n= 28) of patients were nil by mouth.
The resuscitation strategy of 250ml bolus followed by re-assessment was carried out in merely 20% of resuscitation-fluid-days.
In terms of maintenance-fluid-days, fluid prescription and management outcomes are outlined in Table 1.
Conclusions
Knowledge regarding adequate fluid prescription is still lacking in our hospital.
Fluid prescription charts are currently being introduced at MDH which aim to promote an increased awareness and change in culture.
Teaching programmes for junior doctors are necessary to improve knowledge and current practices4,5.
Introduction of a local guideline in the future with the aim of improving outcomes.
Table 1: Fluid prescription audit measures
Maintenance Fluid Prescription
Fluid balance assessment
20%
Daily electrolyte analysis
54%
Indication documented
23%
Plan executed as prescribed
63%
Oral fluid intake documented 3%
Fluid volume appropriate
74%
Urine output documented
14%
Excess sodium
Type of fluid
67%
Insufficient potassium
83%
Rate of fluid
51%
Insufficient glucose
80%
Volumetric pump used
Weight documented 0%
References
Powell AG et al. Undergraduate medical textbooks do not provide adequate information on intravenous fluid therapy: a systematic survey and suggestions for improvement. BMC Med Educ Feb 20;14:35.
National Institute of Health and Care Excellence (NICE).Intravenous Fluid Therapy in Adults in Hospital (CG174) guide.
Tuck JP et al. British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients.
Available from:
4. F Alhomida et al. A retrospective audit of fluid management in patients in an acute hospital and adherence to the GIFTASUP 2009 guidelines. BMC Proceedings 2015, 9(Suppl 1):A22 
5. Walker GE. Intravenous fluid use in the acutely unwell adult medical inpatient: improving practice through a clinical audit process. J R Coll Physicians Edinb 2012, 42:
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