Policy responses and statements
- Name of organisation:
- National Patient Safety Agency
- Name of policy document:
- Draft Patient Safety Alert: Reducing the risk of harm when administering intravenous fluids to children
- Deadline for response:
- 31 March 2006
Background: The National Patient Safety Agency is undertaking a wide stakeholder consultation on recommendations intended to reduce the risk of harm when administering intravenous fluids to children. The NPSA plans to issue final recommendations in the NHS in England and Wales later in 2006.
The recommendations made within this draft Patient Safety Alert relate to the paediatric patient aged one month to 16 years. It refers to practices on general paediatric in-patient areas (including the post-operative scenario) and excludes practices on paediatric and neonatal intensive care units and specialist areas, for example, renal or cardiac units.
Comments and suggestions concerning this draft were requested.
COMMENTS ON
NATIONAL PATIENT SAFETY AGENCY
DRAFT PATIENT SAFETY ALERT: REDUCING THE RISK OF HARM WHEN ADMINISTERING INTRAVENOUS FLUIDS TO CHILDREN
The Royal College of Physicians of Edinburgh is pleased to respond to the National Patient Safety Agency on its draft Patient Safety Alert on Reducing the risk of harm when administering intravenous fluids to children.
The discussion concerning appropriate intravenous fluid replacement for children has been ongoing for some years. The first note of concern about use of hypotonic saline was raised by the NPSA in 2003 following some poor paediatric patient outcomes from hyponatraemia. Along with this were concerns that in 'stressed' children (either surgery without neuroaxial blockade or very high opioid techniques and critically ill children) there was a high risk of hyperglycaemia with associated problems and risk.
This document addresses these problems and is well written and clear in its scope. It excludes Paediatric Intensive Care Units (PICUs) and Neonatal Intensive Care Units (NICUs) from its remit.
There are three key messages:
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Intravenous hypotonic solutions can kill.
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Hyponatraemic encephalopathy is a medical emergency and should be treated using hypertonic intravenous fluids.
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Intravenous fluids should be prescribed extremely carefully.
These three messages are exceedingly important.
Although this document applies to England and Wales there are clearly universal messages here. Equally, they should not be ignored in PICUs and NICUs.
The five factors cited as increasing the risks of hyponatraemia in children (bullet points page 2) are unarguable, and again have wider implications than the scope of this document eg any prescribing requires training, and to fail to train prescribers is a major clinical governance issue. The five action points are succinct and sensible.
In section 2, more thought and explanation should be given to the expression “bolus doses”. There are some clinical situations where true bolus administration eg 20ml/kg or more is given as soon as intravenous access can be achieved. In other situations, isotonic solutions might be more wisely delivered over 30 minutes, an hour or two hours. Resuscitation of an infant with hypernatraemic dehydration, not dealt with in this document, should be approached cautiously in order to reduce the chance of encephalopathy as a result of rapid changes in plasma sodium concentrations.
Also in section 2, very recent data could be incorporated into the advice given with extension of this to children presenting with gastroenteritis. This study1 advises the use of 0.9% saline and with no concerns identified in this approach.
The flow diagram is helpful. The box entitled “Volume of intravenous maintenance fluid” has an ambiguous instruction for children of 10-20kg and over 20kg. The instruction is to give “1000ml plus 50ml/kg/day”. It does not make it clear that the 1000 ml is given over the day with a supplement of 50ml/kg/day. The very inexperienced might give 1000ml rather quickly and then 50ml/kg/day thereafter.
1. K A Neville, C F Verge, A R Rosenberg, M W O'Meara, and J L Walker Isotonic is better than hypotonic saline for intravenous rehydration of children with gastroenteritis: a prospective randomised study Arch. Dis. Child., Mar 2006; 91: 226 - 232.
Copies of this response are available from:
Lesley Lockhart,
Royal College of Physicians of Edinburgh,
9 Queen Street,
Edinburgh,
EH2 1JQ.
Tel: 0131 225 7324 ext 608
Fax: 0131 220 3939
[31 March 2006] |
