Intravenous fluid prescribing is one of the commonest tasks undertaken by doctors in hospitals.¹ Hitherto, fluid prescribing has not been ascribed the same status as drug (especially antibiotics) prescribing. Is this about to change in light of the recent NICE clinical guideline 174 on intravenous fluid prescribing in adult patients in hospital? One can only hope so in view of safety concerns about inappropriate administration of fluids especially in older patients.
The 1999 and 2011 reports of the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) drew attention to the harm that inappropriate fluid administration may be causing in older patients. The 1999 report Extremes of Age showed that one in five older patients receiving intravenous fluids in hospital suffered complications or morbidity due to inappropriate administration.² The 2011 report Knowing the Risks highlighted that older patients were at an increased risk of death within 30 days of having an operation if they had received inadequate or excessive intravenous fluids in the preoperative period.³ These findings should be of concern to doctors including care of the elderly physicians.
Most fluid prescriptions are undertaken by the least experienced doctors in their first year of training (FY1). A study found that 89% of prescriptions were by FY1 doctors.⁴ A local survey we undertook in two different hospitals showed that only approximately 30% of doctors knew the sodium content of 0.9% saline. The results correspond with previous national surveys in the UK which revealed that <50% of junior medical staff knew the same.⁵ Poor knowledge, training and awareness of risks impacts negatively on the quality of fluid prescriptions.
The traditional average weight of 70kg for adult patients does not apply in many frail older patients. A recent audit conducted at our Trust shows that one quarter of older patients in the study weighed on average 50kg or less. This has safety implications in terms of volume of maintenance fluids prescribed. The same caution that is exercised in paediatric practice should apply for adults especially the frail elderly with less than average weight.
The need for a guideline to shape practice has never been greater and could not have been timelier with the publication of NICE guidance in December 2013.6 It should be embraced by all doctors and championed by geriatricians. It has the potential to improve the quality of fluid prescriptions and reduce the risks of harm to older patients. If well utilised, the attention accorded to fluid prescribing with the publication of this guide should enhance our understanding of the need or otherwise for prescribing and improve the vigilance required for monitoring of prescriptions.
It states that intravenous fluid therapy should only be prescribed for older patients whose fluid and electrolyte needs cannot be met by oral or enteral routes. When fluids are prescribed, a monitoring plan should be in place so that fluids can be stopped as soon as possible. An indication for fluid prescription should be provided in all cases. The indication for fluid prescription is represented by four Rs; Resuscitation, Routine maintenance (include patients who are nil by mouth), Replacement or Redistributive. Fluid management strategy should also be clearly written up in the clinical notes and/ or fluid prescription charts.
Routine prescriptions of fluids for older patients should be avoided as should fluids at night to promote sleep unless clinically necessary. Hospitals should audit fluid prescribing practices and put in place interventions for continued improvement to safeguard the safety of older patients.
1. Richard Leach. Fluid management on hospital medical wards. Clin med 2010 Vol 10, No 6: 611-15
2. National Confidential enquiry of Patient Outcome and Death (NCEPOD) 1999 report – Extremes of age
3 National Confidential enquiry of Patient Outcome and Death (NCEPOD) 2011 report – Knowing the risks
4 Lobo DN, Dube MG, Neal KR et al. Problems with solutions: drowning in the brine of an inadequate knowledge base. Clin Nutr 2011; 20:125-30.
5 Powell-Tuck J, Gosling P, Lobo DN et al. British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients.
7 Smita Padhi, Ian Bullock, Lilian Li, Mike Stroud. National Institute for Clinical Excellence CG 174 – December 2013