The impact of the National Patient Safety Agency intravenous fluid alert on iatrogenic hyponatraemia in children

Paediatric Virology and respiratory syncytial virus: An interview with Honorary Senior Lecturer in Paediatric Infectious Diseases Dr Simon B. Drysdale (St. George's, University of London, UK)

Dr Simon B. Drysdale, Consultant and Honorary Senior Lecturer in Paediatric Infectious Diseases at St. George's University Hospitals NHS Foundation Trust and St. George's, University of London, is one of the most talented early career academic specialists in Paediatric Infectious Diseases in the United Kingdom. His main research interest is respiratory syncytial virus (RSV); he is particularly interested in understanding the host susceptibility to RSV, the management of RSV infection and associated health economics and the development of treatments and immunisations/vaccines, which are currently lacking. According to Dr Drysdale, RSV is a significant cause of morbidity and mortality among young infants and older adults, particularly those with co-morbidities. While there is ample RSV epidemiological and healthcare cost data available for young infants and children, more data is required for older children and adults. There are currently several antiviral medications for the treatment of RSV infection in development; however, none have yet progressed beyond Phase 2 clinical trials. Multiple types of novel therapeutic molecules have been developed, including fusion and non-fusion inhibitors and polymerase inhibitors aimed at various RSV targets, such as the F protein and RNA polymerase. In recent years, great strides have been made with regards to an RSV vaccine or monoclonal antibody, with >40 candidates currently in development. A maternal RSV vaccine, which just completed a Phase 3 trial, was shown to have 44% efficacy against hospitalization for RSV lower respiratory tract infection in infants. A new long-acting monoclonal antibody against RSV infection, having shown excellent promise in a Phase 2 trial in infants, is about to be investigated in a Phase 3 clinical trial commencing shortly.

Clinical Practice Guideline: Maintenance Intravenous Fluids in Children

Maintenance intravenous fluids (IVFs) are used to provide critical supportive care for children who are acutely ill. IVFs are required if sufficient fluids cannot be provided by using enteral administration for reasons such as gastrointestinal illness, respiratory compromise, neurologic impairment, a perioperative state, or being moribund from an acute or chronic illness. Despite the common use of maintenance IVFs, there is high variability in fluid prescribing practices and a lack of guidelines for fluid composition administration and electrolyte monitoring. The administration of hypotonic IVFs has been the standard in pediatrics. Concerns have been raised that this approach results in a high incidence of hyponatremia and that isotonic IVFs could prevent the development of hyponatremia. Our goal in this guideline is to provide an evidence-based approach for choosing the tonicity of maintenance IVFs in most patients from 28 days to 18 years of age who require maintenance IVFs. This guideline applies to children in surgical (postoperative) and medical acute-care settings, including critical care and the general inpatient ward. Patients with neurosurgical disorders, congenital or acquired cardiac disease, hepatic disease, cancer, renal dysfunction, diabetes insipidus, voluminous watery diarrhea, or severe burns; neonates who are younger than 28 days old or in the NICU; and adolescents older than 18 years old are excluded. We specifically address the tonicity of maintenance IVFs in children.The Key Action Statement of the subcommittee is as follows:1A: The American Academy of Pediatrics recommends that patients 28 days to 18 years of age requiring maintenance IVFs should receive isotonic solutions with appropriate potassium chloride and dextrose because they significantly decrease the risk of developing hyponatremia (evidence quality: A; recommendation strength: strong).

Intravenous fluid prescribing errors in children: Mixed methods analysis of critical incidents

Introduction

Recent National Institute for Health and Care Excellence (NICE) guidelines aim to improve intravenous (IV) fluid prescribing for children, but existing evidence about how and why fluid prescribing errors occur is limited. Studying this can lead to more effective implementation, through education and systems design.

Aims

Methods

Mixed methods observational study which analysed critical incident reports relating to IV fluid prescribing errors in children aged 0–16, occurring between 2011 and 2015 in UK secondary care. We quantified characteristics and types of errors, then qualitatively analysed narrative descriptions, identifying underlying contributing factors.

Results

In the 40 incidents analysed, principal types of errors were incorrect rate of fluids, inappropriate choice of solution, and incorrect completion of prescription charts. Prescribers had to negotiate complex patients, interactions with other practitioners and teams, and challenging work environments; errors resulted from these inter-related contributing factors.

Conclusions

This study highlights the diverse range and complex nature of IV fluid prescribing errors reported in practice. While these findings have the inherent limitations of critical incident reports, they point to areas of potential improvement in education and systems design. Practising prescribing in context, inducting doctors within the many specialties who contribute to care of children, and educating them in joint working with nurses and pharmacists could help reduce errors.

Neurological symptoms in hospitalised patients: do we assess hyponatraemia with sufficient care?

AIM

To review the incidence of hyponatraemic encephalopathy in children treated in a tertiary care centre hospital, together with the clinical setting and clinical management of these cases.

METHODS

Retrospective descriptive study by chart review of patients admitted to hospital during 2000-2010. Patients older than 1 month were included who had severe hyponatraemia (sodium concentration <125 mmol/L) on admission or during their hospital stay and co-incidental neurological symptoms. Epidemiological, clinical, laboratory and therapeutic data were collected.

RESULTS

We analysed 41 cases of severe hypotonic hyponatraemia and neurological symptoms compatible with hyponatraemic encephalopathy. Boys accounted for 56.1% patients, and the median age was 1 year. Hyponatraemia was acquired in hospital by 61% of the patients, and 88% of those patients were receiving intravenous hypotonic fluids. The most frequent neurological symptom was seizures. The most common therapeutic strategy was sodium supplementation and antiepileptic drugs. Hypertonic fluids were only used in the initial treatment of 16 patients. There were two deaths related to hyponatraemic encephalopathy.

CONCLUSION

Hyponatraemia should always be considered a cause of neurological symptoms in hospitalised patients. Treatment should be prompt to prevent neurological sequelae and death. Current recommendations for fluid management in hospitalised children should be reviewed.

Intravenous maintenance fluids revisited

Intravenous maintenance fluid therapy aims to replace daily urinary and insensible losses for ill children in whom adequate enteric administration of fluids is contraindicated or infeasible. The traditional determination of fluid volumes and composition dates back to Holliday and Segar's seminal article from 1957, which describes the relationship between weight, energy expenditure, and physiologic losses in healthy children. Combined with estimates of daily electrolyte requirements, this information supports the use of the hypotonic maintenance fluids that were widely used in pediatric medicine. However, using hypotonic intravenous fluids in a contemporary hospitalized patient who may have complex physiologic derangements, less caloric expenditure, decreased urinary output, and elevated antidiuretic hormone levels is often not optimal; evidence over the last 2 decades shows that it may lead to an increased incidence of hyponatremia. In this review, we present the evidence for using isotonic rather than hypotonic fluids as intravenous maintenance fluid.