Aim Prior to July 2017, the hospital Trust had over twelve different IV fluid choices and there was no ‘standard’ fluid. This often led to confusion with prescribers and stock issues. The Trust made the decision to switch their routine maintenance fluid choice to Plasma-Lyte in July 2017. This was to simplify, standardise and streamline IV fluid choice, reduce the risk of iatrogenic metabolic disturbances, especially hyponatraemia associated with the current IV fluid use and to bring the Trust up to date with NICE guidelines.¹ An audit was carried out to investigate whether using Plasma-Lyte as the standard maintenance fluid has reduced the risk of hyponatraemia and hyper-chloraemia in patients prescribed maintenance fluids. The objectives were to identify patients prescribed maintenance fluids, check their electrolytes and check that the new IV fluid guideline had been followed appropriately.

Methods Data on patients receiving IV fluids were collected twice a week for 6 weeks, beginning in the first week of December 2017. All ward pharmacists working during the data collection period received guidance on the method of data collection. Once the appropriate details were collected on each chosen day, the forms were passed onto the investigator to process. The electronic prescribing system at the hospital trust enables access to all patients’ blood results and medical notes, therefore, a separate data collection form could be completed with anonymised data retrospectively following the completion of the data collection period.

Results 145 patients were identified as having IV fluid prescribed, 68 of these had been prescribed Plasma-Lyte according to the Trust guidelines, however guidelines were only adhered to 68% of the time, with the other 32% comprising of patients either not having the correct fluid prescribed or patients having the correct fluid prescribed but not having the necessary monitoring required when receiving IV maintenance fluids. There was a marked reduction of patients experiencing hyponatraemia and hyperchloraemia since the introduction of Plasma-Lyte. Only 3% of patients audited experienced hyponatraemia when receiving Plasma-Lyte, compared to 14% from a previous audit of other maintenance fluids.

Conclusion The results shown are not surprising when the actual composition of Plasma-Lyte is evaluated. For example; Plasma-Lyte ± glucose contains 140 mmol/L of sodium and 98 mmol/L of chloride which matches serum exactly and is considered isotonic. Sodium chloride 0.45% only contains 77 mmol/L of sodium and sodium chloride 0.9% contains 154 mmol/L chloride, hence the reasons for hyponatraemia and hyperchloraemia when using these types of fluids. The audit results match what is reported in other controlled trials of fluid choices in that an isotonic fluid should be used as the chosen fluid when hydrating paediatric patients. A further audit in July 2018 would be beneficial to check that patients are continuing to benefit from the introduction of this fluid and not experiencing iatrogenic metabolic disturbances, but also look at other electrolytes such as potassium and to see if adherence to the guidelines has improved.

References

1. NICE ( 2015) Intravenous fluid therapy in children and young people in hospital. NICE guideline 29.

2. Allen, C. Goldman, R. et al. A randomised trial of Plasma-Lyte A and 0.9% sodium chloride in acute paediatric gastroenteritis. BMC Paediatrics 2016;16:117.