Introducing NICE guidelines for intravenous fluid therapy into a district general hospital

Choice of creep or maintenance fluid type and their impact on total daily ICU sodium burden in critically ill patients: A systematic review and meta-analysis

PURPOSE

Maintenance and hidden/creep fluids are a major source of fluid and sodium intake in intensive care unit (ICU) patients. Recent research indicates that low versus high sodium content maintenance fluids could decrease fluid and sodium burden. We conducted a systematic review (SR) with meta-analysis to summarize the impact of maintenance fluid choice on total daily sodium in ICU patients.

MATERIALS AND METHODS

Systematic literature search in Pubmed, Embase, the Cochrane Library and the.

CLINICAL TRIALS REGISTRY

Only controlled clinical trials were included.

EXCLUSION CRITERIA

trials on resuscitation fluids, performed in the emergency department only and in pediatric patients. Primary objective was the reduction in mean total sodium intake with low versus high sodium content maintenance/creep fluids.

RESULTS

Five studies (1105 patients) were included. Heterogeneity was high.Risk of bias was moderate. Mean daily sodium reduction was 117 mmol (95%Confidence Interval [CI] -174; -59; p < 0.001) with low versus high sodium content maintenance/creep fluids. Incidence of hyperchloremia was lower (OR 0.26; 95%CI 0.1; 0.64) with low sodium. There were no differences in the incidences of hyper-/hyponatremia and fluid balances.

CONCLUSION

Using low sodium content maintenance/creep fluids substantially reduces daily sodium burden in adult ICU patients. Significant knowledge/research gaps exist regarding relevance and safety.

TRIAL REGISTRATION

PROSPERO 2022 CRD42022300577 (February 2022).

Multidisciplinary expert panel report on fluid stewardship: perspectives and practice

Although effective and appropriate fluid management is a critical aspect of quality care during hospitalization, the widespread adoption of consistent policies that ensure adequate fluid stewardship has been slow and heterogenous. Despite evidence-based guidelines on fluid management being available, clinical opinions continue to diverge on important aspects of care in this setting, and the consistency of guideline implementation is far from ideal. A multidisciplinary panel of leading practitioners and experts convened to discuss best practices for ongoing staff education, intravenous fluid therapy, new training technologies, and strategies to track the success of institutional fluid stewardship efforts. Fluid leads should be identified in every hospital to ensure consistency in fluid administration and monitoring. In this article, strategies to communicate the importance of effective fluid stewardship for the purposes of education, training, institutional support, and improvement of patient outcomes are reviewed and recommendations are summarized.

Development and validation of an audit tool for fluid management in non-critically ill adults in the emergency department

Especially in the emergency department (ED), it is critical to identify weaknesses in prescribing behavior of IV maintenance fluids to ensure a qualitative 24-h fluid management plan. The primary aim of this study was to develop an audit instrument to assess the pitfalls in documentation and prescribing habits of IV fluid therapy for non-critically ill patients admitted to the ED. In this study, an expert panel initially designed the tool. During different phases, adaptations were made to optimize inter-rater agreement (Fleiss' kappa, κ) and validity was determined based on the application of the tool on randomly selected electronic ED patient records. Second, the IV fluid prescription's appropriateness was addressed. The final tool consists of three parts: fluid status assessment, evaluation of maintenance fluid needs and, if present, a limited appropriateness check of the fluid prescription. A manual enhanced inter-rater agreement. κ-values achieved the target value (0.40) after three adaptation rounds, except for the category of 'clinical observations' in the assessment part (κ = 0.531, 95% CI 0.528-0.534), which was acceptable. A check of the IV fluid's indication and volume was only possible with an additional expert evaluation to conclude on prescription appropriateness. Criterion related validity of the final version was high (93.4%). To conclude, the instrument is considered reliable and can be used in clinical practice to evaluate ED fluid management. Thorough documentation is essential to evaluate the appropriateness of the IV fluid prescription, to improve information transfer on IV fluid therapy to the ward and to facilitate retrospective chart review of ED prescribing behavior.