New guidelines from the health watchdog the National Institute for Health and Care Excellence (NICE) on the use of intravenous (IV) drips have prompted a flurry of headlines, with The Guardian reporting that, "Thousands of patients [are] dying from incorrect use of IV drips", and The Daily Telegraph claiming that, "Tens of thousands harmed in hospital by IV drip blunders".
Both newspapers present misleading figures that have been taken out of context. Their stats, which state that one in three patients die from too much fluid within days of surgery, are taken from the National Confidential Enquiry into Patient Outcome and Death (2011). The enquiry reported on a study of just 569 high-risk patients. Three of the patients were given too much fluid before their operation and one died.
Only approximately 10% of people having surgery are considered high risk. In fact, the NICE report says that less than 1% of all patients undergoing surgery die during the same hospital admission.
Still, the rates of non-fatal complications reported in the guidelines are disturbingly high and should be seen as a call to improve patient safety in this area.
What are intravenous (IV) drips used for?
Intravenous (IV) drips are used for a variety of reasons, including:
- giving daily fluid to people who cannot drink water, for example during surgery or because they are vomiting
- to replace lost fluid, such as from bleeding or severe diarrhoea
- to correct chemical or metabolic imbalance, such as having too much potassium inside the body
- to manage hydration if fluid is not being distributed around the body normally
The amount and composition of fluid given depends on a person's weight, physical condition, medical problems and medication.
What has prompted the warning?
The National Institute for Health and Care Excellence (NICE) has issued guidance on when and how IV fluids should be prescribed.
It states that there is evidence that as many as one in five patients on IV fluids and electrolytes (salts and minerals) suffer complications because of inappropriate use.
What are the risks of incorrect use?
If a patient receives too little fluid, it increases the risk of dehydration and in severe cases can lead to kidney failure.
The risks of receiving too much fluid often depend on individual circumstances, but they can include:
- excess fluid collecting inside the lungs, which can cause breathing difficulties and increased risk of pneumonia
- swelling of the ankles
- an imbalance of electrolytes in the blood, which can disrupt organs
- heart failure in serious cases
There are different types and composition of fluids, which must be balanced to ensure electrolyte levels are correct and to keep the fluid circulating through the blood vessels.
What has NICE recommended?
NICE has provided comprehensive guidelines on prescribing IV fluids for medical professionals. Most of the recommendations are of a very technical nature and many are probably only of interest to health professionals. The recommendations can be read in full online.
They include increased education of health professionals on the principles of fluid management, regular checks of patients on fluids for possible "red flags" that indicate they are receiving too much or too little fluid, and that hospitals should identify an "IV fluids champion" to lead best practice for the management of IV fluids.
The NICE guidance concludes by making a number of recommendations for further research into fluid management, such as:
- investigation into exactly how common complications of IV fluid therapy are
- identifying what the best type of fluid is for people who are in hypovolemic shock (where severe blood and fluid loss has occurred)
- identifying the most effective training methods for hospitals to use to improve care standards
Speaking at a press conference, one of the authors of the guidelines, Dr Mike Stroud, said: "It is astonishing really that doctors are not well educated in fluid therapy, but because it is not a speciality, it has fallen through the cracks.
"This new NICE guideline has training and education at its heart and will play a vital role in making sure that staff at all levels in the NHS deliver consistent, high-quality care for all patients."