Guideline Ministry of Health, NSW 73 Miller Street North Sydney NSW 2060 Locked Mail Bag 961 North Sydney NSW 2059 Telephone (02) 9391 9000 Fax (02) 9391 9101 http://www.health.nsw.gov.au/policies/ space space Standards for Paediatric Intravenous Fluids: NSW Health (second edition) space Document Number GL2015_008 Publication date 31-Aug-2015 Functional Sub group Clinical/ Patient Services - Medical Treatment Clinical/ Patient Services - Baby and child Summary The Standards address the appropriate choice of IV fluids and measures related to their procurement, storage and safe administration. The key changes in the second edition of the Standards regarding the content of IV fluids for children and neonates include: incorporating further evidence supporting the use of isotonic saline solutions in IV maintenance therapy; standardising the use of 1000mL bags in the care of children beyond the specialist children's hospitals; and incorporating Special Care Nursery practice and clarification around IV fluids for neonates. Replaces Doc. No. Standards for Paediatric Intravenous Fluids: NSW Health [GL2014_009] Author Branch NSW Kids and Families Branch contact NSW Kids and Families 02 9424 5978 Applies to Local Health Districts, Specialty Network Governed Statutory Health Corporations, Public Hospitals Audience All medical and nursing staff and pharmacy and procurement staff Distributed to Public Health System, Divisions of General Practice, NSW Ambulance Service, Ministry of Health, Private Hospitals and Day Procedure Centres, Tertiary Education Institutes Review date 31-Aug-2020 Policy Manual Patient Matters File No. H15/18617 Status Active Director-General
Transcript
Guideline
Ministry of Health, NSW73 Miller Street North Sydney NSW 2060
Locked Mail Bag 961 North Sydney NSW 2059Telephone (02) 9391 9000 Fax (02) 9391 9101
http://www.health.nsw.gov.au/policies/
spacespace
Standards for Paediatric Intravenous Fluids: NSW Health (secondedition)
spaceDocument Number GL2015_008Publication date 31-Aug-2015
Functional Sub group Clinical/ Patient Services - Medical TreatmentClinical/ Patient Services - Baby and child
Summary The Standards address the appropriate choice of IV fluids and measuresrelated to their procurement, storage and safe administration. The keychanges in the second edition of the Standards regarding the content ofIV fluids for children and neonates include: incorporating further evidencesupporting the use of isotonic saline solutions in IV maintenance therapy;standardising the use of 1000mL bags in the care of children beyond thespecialist children's hospitals; and incorporating Special Care Nurserypractice and clarification around IV fluids for neonates.
Replaces Doc. No. Standards for Paediatric Intravenous Fluids: NSW Health [GL2014_009]Author Branch NSW Kids and FamiliesBranch contact NSW Kids and Families 02 9424 5978
Applies to Local Health Districts, Specialty Network Governed Statutory HealthCorporations, Public Hospitals
Audience All medical and nursing staff and pharmacy and procurement staffDistributed to Public Health System, Divisions of General Practice, NSW Ambulance
Service, Ministry of Health, Private Hospitals and Day Procedure Centres,Tertiary Education Institutes
Review date 31-Aug-2020Policy Manual Patient Matters
File No. H15/18617Status Active
Director-General
GUIDELINE SUMMARY
STANDARDS FOR PAEDIATRIC IV FLUIDS: NSW HEALTH
PURPOSE Intravenous fluids are important components of appropriate care for hospitalised children. Reports in the medical literature and warnings issued in other countries have highlighted the risks associated with use of low sodium content fluids. The importance of appropriate glucose content has also been identified.
The NSW Chief Paediatrician was tasked to engage clinical experts, HealthShare and a range of other partners in the development of state wide standards across all NSW facilities. The resulting Standards for Paediatric IV Fluids: NSW Health addresses fluid content, bag size, labelling, administration, procurement and storage.
Emerging new evidence and clinical experience motivated an early revision of the Standards, resulting in this second edition.
KEY PRINCIPLES The intended outcomes of the first edition of the standards regarding the content of IV fluids in children and neonates included:
x Reducing the risk of hyponatremia through increased sodium content and limiting the use of low sodium containing fluids
x Addressing glucose requirements of children and neonates through increased glucose content
x Consistent inclusion of potassium chloride as early as considered safe and appropriate.
The key changes in the second edition of the Standards regarding the content of IV fluids for children and neonates include:
x Incorporating further evidence supporting the use of isotonic saline solutions in IV maintenance therapy
x Standardising the use of 1000mL bags in the care of children beyond the specialist children’s hospitals
x Incorporating Special Care Nursery practice and clarification around IV fluids for neonates
The Statement of the Standards for Paediatric Intravenous Fluids: NSW Health (page 8) provides a summary of the recommended standards.
GL2015_008 Issue date: August-2015 Page 1 of 2
GUIDELINE SUMMARY
USE OF THE GUIDELINE The following priorities have been identified to facilitate the implementation of Standards for Paediatric Intravenous Fluids: NSW Health (second edition) into all relevant clinical areas; Communication, Education and Raising Awareness, Integration into Practice, Procurement and Monitoring.
REVISION HISTORY Version Approved by Amendment notes August 2015 (GL2015_008)
Deputy Secretary, Population and Public Health
Further evidence supporting the use of isotonic saline solutions in IV maintenance therapy in paediatrics.
June 2014 (GL2014_009)
Deputy Secretary, Population and Public Health
New evidence
ATTACHMENTS 1. Standards for Paediatric Intravenous Fluids: NSW Health (second edition)
GL2015_008 Issue date: August-2015 Page 2 of 2
L2014_XXX Issue date: August 2014 Revision due: August 2019
Page 2 of 30
Issue date: August 2015 GL2015_008
Standards for
PAEDIATRIC IV FLUIDS Second Edition GUIDELINE
+
L2014_XXX Issue date: August 2014 Revision due: August 2019
7. DEVELOPMENT OF THE STANDARDS AND THE HEALTHSHARE NSW CONTRACT....................................................................................................................... 4
9. RELATIONSHIP WITH NATIONAL INTERIM GUIDELINES ............................................. 5
10. SUMMARY STATEMENT OF STANDARDS FOR PAEDIATRIC INTRAVENOUS FLUIDS (Second Edition) ................................................................................................. 6
11. TABLE OF PAEDIATRIC INTRAVENOUS SOLUTIONS (Fluids incorporated in the Summary Statement of Standards for Paediatric IV Fluids: NSW Health) ................... 7
12.1. Appendix 1 – Standards For Paediatric IV Fluids: NSW Health Working Group And Implementation Taskforce Membership ............................................................. 8
12.2. APPENDIX 2 - Consultation Undertaken Formally With Relevant Organisations In Developing The Standards For Paediatric IV Fluids: NSW Health (First Edition)..... 12
12.3. APPENDIX 3 – Labelling Practice ........................................................................... 13
12.4. APPENDIX 4 – Summary Table Of Stages In Development Of The Standards For Paediatric IV Fluids ................................................................................................. 17
Standards for Paediatric IV Fluids: NSW Health (second edition)
1. EXECUTIVE SUMMARY
Intravenous fluids are important components of appropriate care for hospitalised children. Reports in the medical literature and warnings issued in other countries have highlighted the risks associated with use of low sodium content fluids. The importance of appropriate glucose content has also been identified, and some evidence suggests risks associated with high chloride in particular circumstances.
Individual or facility based responses to the changing literature, along with the interim recommendations of a national expert group convened under the auspices of Children’s Healthcare Australasia (CHA), had led to variable practices across NSW Health hospitals with consequent inconsistencies and risks. The NSW Chief Paediatrician was tasked to engage clinical experts, HealthShare NSW and a range of other partners in the development of statewide standards across all NSW facilities. The resultant Standards for Paediatric IV Fluids: NSW Health (first edition) addressed fluid content, bag size, labelling, administration, procurement and storage.
The intended outcomes of the Standards (first edition) regarding the content of IV fluids in children and neonates included:
x Reducing the risk of hyponatraemia through increased sodium content and limiting the use of low sodium containing fluids
x Addressing glucose requirements of children and neonates through increased glucose content
x Consistent inclusion of potassium chloride as early as considered safe and appropriate.
Following the introduction of the first edition of the Standards, clinician expert feedback, clinical incident reviews and product usage were closely monitored. Emerging new evidence confirmed the safety and efficacy of the use of isotonic solutions for intravenous fluid maintenance therapy in infants and children. The consequent early revision of the Standards has led to a second edition. While at the time of the publication of the first edition consensus was readily reached for recommendations regarding fluid content across NSW, the proposed size of paediatric fluid bags (500mL v 1000mL) was left to the discretion of Local Health Districts (LHDs) and Speciality Health Networks (SHNs). The fluid types and volumes purchased following the introduction of the Standards across the State were monitored and further discussions followed. In the second edition consensus was reached by clinicians with regard to paediatric fluid bag sizes of 1000mL. The safety concerns associated with the larger bags for children were alleviated by the widespread and consistent use of IV pumps and inline burettes. For neonates, 500mL bags (or less) continue to be recommended.
The key changes in the second edition of the Standards for Paediatric IV Fluids include:
x Incorporating further evidence supporting the use of isotonic saline solutions in IV maintenance therapy
x Standardising the use of 1000mL bags in the care of children, beyond the specialist children’s hospitals
x Incorporating Special Care Nursery practice and clarification of neonatal IV fluids A succinct Summary Statement of the Standards presents the key messages and related actions on a single page.
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2. INTRODUCTION
Intravenous (IV) fluids are frequently used in hospitalised children, predominantly to maintain hydration and haemodynamic stability as well as for glucose replacement. Historically, low sodium content fluids have been used for both maintenance and deficit replacement. However, burgeoning medical literature has highlighted the risk of hyponatraemia with their use and the particular dangers of fluids with extremely low sodium content1-9,15,16,18. A number of countries have issued warnings against this practice10-
12. Increasingly, the published information1-12 supports the use of higher sodium content isotonic fluids to prevent hyponatraemia10,16,18, as well as the need for adequate glucose delivery to prevent hypoglycaemia6. Studies in critically ill adult patients13, as well as in children15, have also suggested a preference for balanced salt solutions, as exemplified by Plasma-Lyte148, to address risk of hyperchloraemia. As evidence continues to emerge and best practice evolves, clinician discretion, informed by appropriate clinical and laboratory data, is vital in all situations.
In response to the growing literature and in recognition of adverse events, clinicians undertook to supplement existing manufactured fluids within paediatric facilities. This practice introduced considerable risk of both dosing error and infection. A national expert group was convened under the auspices of CHA and interim guidelines were developed recommending appropriate fluid content. Commencing in 2010, the recommendations were adopted by the Children’s Hospitals in NSW, who are members of CHA. They added a further change to exclusively utilise the 1000mL bag size in order to improve both quality and efficiency. Traditionally, 500mL bags have been used for children and neonates in NSW, a distinguishing feature from adult practice. The resultant disconnect between the Children’s Hospitals and other facilities highlighted the importance of standardisation of IV fluids across all NSW services. The risks and confusion were compounded by the regular rotations of junior medical staff and other workforce mobility as well as the very frequent movement of patients between secondary and tertiary paediatric facilities. By the time of the second edition of the Standards, the practice of 1000mL bags in paediatrics had begun to extend beyond the Children’s Hospitals.
3. FLUID CONTENT: INTENDED OUTCOMES
The intended outcomes of the Standards (first edition) regarding the content of IV fluids in children and neonates included:
x Reducing the risk of hyponatraemia through increased sodium content and limiting the use of low sodium containing fluids
x Addressing glucose requirements of children and neonates through increased glucose content
x Consistent inclusion of potassium chloride as early as considered safe and appropriate
The key changes in the second edition of the Standards regarding the content of IV fluids for children and neonates include:
x Incorporating further evidence supporting the use of isotonic saline solutions in IV maintenance therapy
GL2015_008 Issue date: August 2015
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Standards for Paediatric IV Fluids: NSW Health (second edition)
x Standardising the use of 1000mL bags in the care of children, beyond the specialist children’s hospitals
x Incorporating Special Care Nursery practice and clarification of neonatal IV fluids
4. LABELLING
Subsequent to the tendering process and contractual agreements completed by HealthShare NSW, further consultation with the contracted manufacturers, Baxter Healthcare Australia, was undertaken. This led to revisions of bag labelling practice with substantial clarification and improvement. The important messages and changes in labelling are highlighted in the Summary Statement of Standards and in Appendix 3.
The National Recommendations for User-applied Labelling of Injectable Medicines, Fluids and Lines (Labelling Recommendations) aim to enhance patient safety with clear, practical labelling and identify, what should be labelled, what should be included on the label and where the label should be placed. The Labelling recommendations refer to user (clinician) applied labels. All paediatric and neonatal intravenous fluids are to be labelled as per the Labelling Recommendations17,19.
5. FLUID BAG SIZE AND INTRAVENOUS FLUID THERAPY ADMINISTRATION
While consensus on fluid content across NSW was readily reached for the first edition of the standards, the proposed size of the fluid bag (500mL v 1000mL) was more contentious. The fluid types and volumes purchased following the introduction of the first edition of the Standards across the State were monitored and movement towards 1000mL bags was noted. The previous challenges to reach consensus to standardise fluid bag sizes for children have been alleviated, as safety concerns have been addressed by the widespread availability and consistent use of IV pumps and inline burettes for paediatric IV fluid therapy. In the second edition consensus on paediatric fluid bag sizes was reached by clinicians with 1000mL bags for use in children being consistently recommended.
This recommendation supersedes the prior Policy Directive PD2010_034, Section 3.3.11 mandate of 500mL bag size for all paediatric use. For neonates 500mL bags (or less) continue to be recommended.
In accordance with NSW Health Policy Directive PD2010_034, Section 3.3.10: “Paediatric infusion sets with an inline burette must be used for all children requiring intravenous therapy. An infusion pump should be used in all children”. These aspects of the Policy Directive are maintained and strongly reinforced. Current settings where variations of this policy are recognised include Ambulance Service of NSW, operating theatres and acute resuscitation scenarios. For the safety of paediatric and neonatal patients, the use of both infusion pumps AND inline burettes is strongly recommended with all maintenance and replacement fluids. Fluids should be administered with the same caution that is used with any intravenous drug, taking into consideration, the type, dose, indications, contraindications, potential for toxicity, and cost13. IV fluids containing potassium chloride are potentially hazardous and should be administered with extreme caution. Hourly observations of the IV fluids being administered and IV cannula site should be documented on the NSW paediatric fluid balance chart.
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6. SAFETY
6.1. ADDITIONAL MEASURES FOR LOW SODIUM CONTENT PRODUCTS
An important development in the NSW Standards is deliberately restricting access to extremely low sodium content products, such as 0.225%, 0.22% and 0.18% sodium chloride. A 0.22(5)% sodium chloride product will continue to be used in neonatal practice with 10% glucose. Accordingly, LHDs/ SHNs are being asked to ensure that such products be stored only in dedicated maternity/neonatal storage unit. Since adult practice may also include such products, it is proposed that discussions take place, informed by the broader literature, to explore their potential future alignment with paediatric initiatives. In the meantime, the manufacturers will take steps to ensure that the labels of any such products include a warning regarding low sodium content.
6.2. PLASMA-LYTE 148
The Standards acknowledge the emerging evidence for the use of balanced salt solutions, in particular, Plasma-Lyte 14813,15. This option is incorporated in the revised Standards as an alternative for both maintenance and rehydration, but only under the direction of a Specialist. The results of compatibility studies with Plasma-Lyte 148 and commonly used medications are awaited to inform any firmer recommendations related to the use of Plasma-Lyte148 in paediatric and neonatal care. Plasma-Lyte 148 is the only form of Plasma-Lyte considered appropriate in children. It is available with or without 5% glucose. Plasma-Lyte 148 and Plasma-Lyte 148 + 5% glucose contain 5mmol/L potassium chloride. The need for a product with a higher potassium chloride content is also under consideration.
7. DEVELOPMENT OF THE STANDARDS AND THE HEALTHSHARE NSW CONTRACT
The NSW Chief Paediatrician was tasked to lead a process of consensus, standardisation and appropriate implementation of practice across all NSW facilities. The process undertaken included extensive consultation and input from a range of experts across medical, nursing, pharmacy and management domains from a variety of metropolitan and rural settings. The composition of the NSW Standards for Paediatric IV Fluids Working Party, subsequent Implementation Taskforce and Committee memberships for the second edition are detailed in Appendix 1. Formal organisational consultations are listed in Appendix 2.
Partnering with HealthShare NSW in understanding and informing procurement requirements was identified as an essential, albeit complex, component. HealthShare NSW undertook a formal tendering process leading to an appropriate contract, incorporating the recommended paediatric IV fluids. The contracted products are detailed in Table 1. HealthShare NSW continues to provide procurement advice to Local Health Districts (LHDs).
Following the introduction of the first edition of the Standards, clinician expert feedback, clinical incident reviews and product usage were closely monitored. An Information
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Standards for Paediatric IV Fluids: NSW Health (second edition)
Bulletin (IB2014_066) was published to advise clinicians and managers about the products and address procurement challenges associated with the implementation of the Standards. It is important to recognise that costs, and consequently pricing, will be influenced by, and modified according to, consumption across NSW and nationally.
Emerging new evidence and clinical experience motivated the early revision of the Standards, with the resulting second edition15,16.
8. SYSTEM-WIDE ENGAGEMENT
The Standards described in this document address the appropriate choice of IV fluids and measures related to their procurement, storage and safe administration. The Summary Statement of Standards for Paediatric IV Fluids: NSW Health presents the key messages and related actions on a single page (Page 6). These are not clinical practice guidelines and do not address clinical assessment, calculations of fluid or electrolyte requirements or their monitoring and appropriate responses to such data. It is noted, however, that a number of existing clinical practice guidelines, educational resources and other documents that specifically mention IV fluid content may need to be updated.
The NSW Paediatric IV Fluid Ordering chart is being revised to be consistent with the Standards. The Paediatric IV Fluids education module in the Skills in Paediatrics (SkIP) program is being revised. In addition, the DETECT Junior education resources (part of the Between the Flags program) will be updated to reflect these Standards. The development of any related resources by the Health Education and Training Institute (HETI) will also be informed by these Standards. Educational resources related to the content and use of Plasma-Lyte148 will be developed, as appropriate, to accompany future recommendations for its use in paediatrics and neonates.
The related communication strategy includes correspondence to LHD Chief Executives, SHNs, Pillars, clinician organisations as well as all partners engaged in the consultation process.
9. RELATIONSHIP WITH NATIONAL INTERIM GUIDELINES
A number of changes have emerged from the CHA interim guidelines to the Standards for Paediatric IV Fluids: NSW Health (first and second editions). These are summarised in Appendix 4 In particular, while the CHA recommendations did not include neonatal practice, the first edition of the Standards incorporated appropriate practice for neonates presenting to emergency departments and/or readmitted to children’s wards. The practice in special care and intensive care nurseries was not addressed in either document. The second edition of the Standards incorporates special care nurseries but not intensive care nurseries. Although CHA made certain recommendations for intra-operative and post-operative fluid management, this is considered beyond the remit of the Standards at this time. It is acknowledged that Hartmann’s Solution is used in peri-operative and intensive care settings and balanced salt solutions are incorporated into the NSW Standards as alternatives but only under the direction of medical specialists.
Standards for Paediatric IV Fluids: NSW Health (second edition)
12. APPENDICES 12.1. Appendix 1 – Standards for Paediatric IV Fluids: NSW Health
Working Group and Implementation Taskforce Membership Committee membership (Second Edition)
Name Position Prof Les White Chair
NSW Chief Paediatrician, NSW Kids and Families
Sandra Babekuhl Paediatric Clinical Nurse Consultant, Mid North Coast LHD
Peter Barclay Director of Pharmacy, Sydney Children’s Hospitals Network, Westmead
Pauline Best Paediatric Nurse Educator, St George Hospital, SESLHD Dr Srinivas Bolisetty Senior Staff Specialist, Newborn Services, Royal Hospital for Women Dr Paul Craven Neonatologist, Hunter New England LHD Dr Stuart Crisp Rural Paediatrician, Western NSW LHD
Mandy Crowley Baxter Healthcare
Deborah Endean Pharmaceutical Contracts Manager, HealthShare NSW Dr Joanne Ging
Head of General Medicine, Sydney Children's Hospitals Network, Westmead Dr Robert Guaran Neonatologist, NSW Pregnancy and newborn Services Network
Catherine Jones Standardisation of Care Coordinator, Paediatric Healthcare Team, NSW Kids and Families
Margaret Kelly Senior Manager, Paediatric Healthcare Team, NSW Kids and Families
Tina Kendrick Clinical Nurse Consultant, Newborn & paediatric Emergency Transport Service
Gail Mondy Director, Maternal, Child & Family Health, NSW Kids and Families Dr Rob Morton Rural GP, VMO, Southern NSW LHD Dr Kristen Neville
Endocrinologist, Sydney Children’s Hospitals Network, Randwick
Dr Susan Phin Staff Specialist, Emergency Department, Sydney Children's Hospitals Network, Westmead
Tomas Ratoni Paediatric Clinical Nurse Consultant, Northern NSW LHD Dr David Schell Intensivist, PICU, Sydney Children’s Hospitals Network, Westmead Natalie Tasker Medication Safety Pharmacist, Sydney Children’s Hospitals Network Jane Wardle Neonatal Clinical Nurse Consultant, Gosford Hospital, Central Coast
LHD
Ian Wright Professor of Paediatrics, Wollongong Hospital, Illawara Shoalhaven LHD
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Standards for Paediatric IV Fluids: NSW Health (second edition)
Neonatal IV Fluids sub-committee membership (Second Edition)
Name Position Dr Paul Craven Chair
Neonatologist, Hunter New England LHD
Pauline Best Paediatric Nurse Educator, St George Hospital, South Eastern Sydney LHD
Dr Srinivas Bolisetty Senior Staff Specialist, Newborn Services, Royal Hospital for Women Dr Stuart Crisp Rural Paediatrician, Western NSW LHD Dr Joanne Ging
Head of General Medicine, Sydney Children’s Hospitals Network, Westmead
Dr Robert Guaran Neonatologist, NSW Pregnancy and newborn Services Network Dr Keith Howard Paediatrician, Hunter New England LHD/ Medical Lead Children’s
Healthcare Network, Northern
Catherine Jones Standardisation of Care Coordinator, Paediatric Healthcare Team, NSW Kids and Families
Tina Kendrick Clinical Nurse Consultant, Newborn & paediatric Emergency Transport Service
Dr Rob Morton Rural GP, VMO, Southern NSW LHD Dr Matthew O’Meara Head of Emergency, Sydney Children’s Hospitals Network,
Randwick Dr Susan Phin Staff Specialist, Emergency Department, Sydney Children's
Hospitals Network, Westmead
Tomas Ratoni Paediatric Clinical Nurse Consultant, Northern NSW LHD Dr Robert Slade Paediatrician, Northern Sydney LHD/ Medical Lead Children’s
Healthcare Network, Southern
Helen Stevens Paediatric Clinical Nurse Consultant, Hunter New England LHD Jane Wardle Neonatal Clinical Nurse Consultant, Gosford Hospital, Central Coast
LHD Ian Wright Professor of Paediatrics, Wollongong Hospital, Illawarra Shoalhaven
LHD
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Standards for Paediatric IV Fluids: NSW Health (second edition)
Working Group membership (First Edition)
Name Position Dr Kristen Neville Co-Chair
Endocrinologist, Sydney Children’s Hospitals Network, Randwick
Dr Joanne Ging Co-Chair
Clinical Director, Division of Women’s Children’s and Family Health, Hornsby Ku-ring-gai Health Service, Northern Sydney LHD Prof Les White
Sponsor NSW Chief Paediatrician, NSW Kids and Families
Dr Chris Webber Deputy Medical Director, Newborn & paediatric Emergency Transport Service and Emergency Physician, Sydney Children’s Hospitals Network
Dr Damien McKay Chief Resident Medical Officer, Sydney Children’s Hospitals Network, Westmead
Elizabeth Kepreotes Clinical Improvement Coordinator, John Hunter Children’s Hospital, Kaleidoscope
Karyn Fahy Co-ordinator, Western Child Health Network Pauline Best Paediatric Nurse Educator, St George Hospital, South Eastern
Sydney LHD Peter Barclay Deputy Director of Pharmacy, Sydney Children’s Hospitals
Network, Westmead Dr Richard Lennon Emergency Specialist, Royal North Shore Hospital, Northern
Sydney LHD
Dr Rob Morton Rural GP, VMO, Southern NSW LHD Robert Pearce Director of Pharmacy, John Hunter Children’s Hospital, Hunter New
England LHD Sandra Babekuhl Paediatric Clinical Nurse Consultant, Mid North Coast LHD Dr Sean Kennedy Nephrologist, Sydney Children’s Hospitals Network, Randwick Dr Stuart Crisp Rural Paediatrician, Western NSW LHD Dr Susan Phin Staff Specialist, Emergency Department, Sydney Children’s
Hospitals Network, Westmead Trish Boss Program Manager, Paediatric Services, Statewide and Rural
Health Services and Capital Development Branch, NSW Ministry of Health (MoH)
Dr Bruce King Endocrinologist, John Hunter Children’s Hospital, Hunter New England LHD
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Roger Oswald Team Leader, Business Procurement Services, HealthShare NSW Deborah Endean Pharmaceutical Contracts Manager, HealthShare NSW Dr Kristen Neville Endocrinologist, Sydney Children’s Hospitals Network, Randwick Dr Joanne Ging Clinical Director, Division of Women’s Children’s and Family
Health, Hornsby Ku-ring-gai Health Service, Northern Sydney LHD
Trish Boss Program Manager, Paediatric Services, Statewide and Rural Health Services and Capital Development Branch, NSW Ministry of Health
Peter Barclay Deputy Director of Pharmacy, Sydney Children’s Hospitals Network, Westmead
Sandra Babekuhl Paediatric Clinical Nurse Consultant, Mid North Coast LHD Dr Rob Morton Rural GP, VMO, Southern NSW LHD Dr Stuart Crisp Rural Paediatrician, Western NSW LHD Pauline Best Paediatric Nurse Educator, St George Hospital, South Eastern
Sydney LHD
Margaret Kelly Greater Eastern and Southern Child Health Network
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Standards for Paediatric IV Fluids: NSW Health (second edition)
12.2. APPENDIX 2 - Consultation Undertaken Formally With Relevant Organisations in Developing the Standards for Paediatric IV Fluids: NSW Health (First Edition)
Position Organisation
Chief Executive Ambulance Service of NSW
Chair Anaesthetic Advisory Group
Medical Science Liaison, Medication Delivery; Market Manager, Medication Delivery; Business Manager
Baxter Healthcare Australia Pty Ltd
Chief Executive Children’s Healthcare Australasia
Chief Executive Clinical Excellence Commission
Pharmaceutical Contracts Manager; Team Leader Business Procurement Services
HealthShare NSW
Chair Metropolitan Level 4 Paediatric Units
State Director Newborn and paediatric Emergency Transport Service
Coordinators and CNCs NSW Children’s Healthcare Network
Chief Pharmacist NSW Health
Chair NSW Health Forms Committee
Operations Manager NSW Pregnancy and newborn Services Network
Chair NSW Rural Doctors Network
Chair Paediatric Intensive Care Advisory Group
Chair Pharmacy Advisors Group, NSW Ministry of Health
President Rural Doctors Association
Director Critical Care Sydney Children’s Hospitals Network, Randwick
Director of Anaesthesia Sydney Children’s Hospitals Network, Westmead
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Standards for Paediatric IV Fluids: NSW Health (second edition)
12.3. APPENDIX 3 – Labelling practice For base fluids (proposed label with paediatric advisory statement*)
* Product label for AHB1064 as it currently appears in the Paediatric Standards is not an approved TGA product label
Batch, expiry and recyclable symbol denoted here
Advisory statements added for paediatrics
Reverse printing in product label to differentiate from
other solutions
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Standards for Paediatric IV Fluids: NSW Health (second edition)
For high risk additives
Batch, expiry and recyclable symbol denoted here
Advisory statements added for paediatrics
Barcode added
Standardisation of units used, keeping in mind TGA requirements for future registration
Emphasis on high-risk active ingredient
Red ink to be used to highlight potassium
content
Critical information moved to the bottom which remains
visible as the bag empties
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Standards for Paediatric IV Fluids: NSW Health (second edition)
For low sodium solutions
Batch, expiry and recyclable symbol denoted here
Australian made symbol added
Cautionary statement differs for low sodium containing solutions
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Standards for Paediatric IV Fluids: NSW Health (second edition)
For balanced salt solutions
Batch, expiry and recyclable symbol denoted here
The new format minimises label clutter, placing
emphasis on important clinical information such
as solution ingredients,
concentration and tonicity.
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ium
chl
orid
e +5
%
gluc
ose
+/-2
0mm
ol/L
pot
assi
um
chlo
ride
0.45
% s
odiu
m c
hlor
ide
+ 5%
glu
cose
+/-
20m
mol
/L p
otas
sium
chl
orid
e (n
ote
disc
retio
nary
use
of p
otas
sium
chl
orid
e co
nsis
tent
with
CHA
reco
mm
enda
tion)
O
R es
peci
ally
whe
re th
ere
is p
re-e
xistin
g hy
pona
traem
ia, o
r non
-osm
otic
ADH
se
cret
ion
(e.g
. pos
t-op,
resp
irato
ry, C
NS d
isea
se)
0.9%
sod
ium
chl
orid
e +
5% g
luco
se +
/- 20
mm
ol/L
pot
assi
um c
hlor
ide
OR
Pla
sma-
Lyte
148
+ 5%
glu
cose
(Chi
ldre
n’s
Hos
pita
ls o
nly)
0.9%
sod
ium
chl
orid
e +
5% g
luco
se +
/- po
tass
ium
chl
orid
e 20
mm
ol/L
Al
tern
ativ
ely
and
ONL
Y un
der d
irect
ion
of S
peci
alist
: x
0.45
% s
odiu
m c
hlor
ide
+ 5%
glu
cose
+/-
pota
ssiu
m c
hlor
ide
20m
mol
/L,
x or
Pla
sma-
Lyte
148
+ 5%
glu
cose
If el
ectro
lyte
s ar
e ou
tsid
e th
e no
rmal
rang
e, d
iscu
ssio
n w
ith a
spe
cial
ist is
nec
essa
ry
Peri
and
intra
-op
erat
ive
perio
d 0.
9% s
odiu
m c
hlor
ide
+1%
gl
ucos
e 1%
glu
cose
sol
utio
ns N
OT
supp
orte
d
Furth
er c
onsu
ltatio
n w
ith p
aedi
atric
ana
esth
etic
pro
fess
iona
l and
sta
te o
rgan
isat
ions
re
com
men
ded.
Har
tman
n’s
solu
tion
ofte
n us
ed p
eri-o
pera
tivel
y.
No c
hang
e fro
m 1
st E
ditio
n
Neon
ates
(<1
mon
th c
orre
cted
) (Th
e 2n
d Ed
ition
Stan
dard
s fo
r Pae
diat
ric IV
Flu
ids:
NSW
Hea
lth in
corp
orat
es S
peci
al C
are
Nurs
ery
prac
tices
(not
NIC
U)
Resu
scita
tion/
Bo
lus
0.9%
sod
ium
chl
orid
e or
H
artm
ann’
s (N
O g
luco
se)
0.9%
sod
ium
chl
orid
e 0.
9% s
odiu
m c
hlor
ide
Repl
acem
ent
(deh
ydra
tion
or
ongo
ing
loss
es)
No
reco
mm
enda
tion
0.45
% s
odiu
m c
hlor
ide
+10%
glu
cose
+/-
20m
mol
/L p
otas
sium
chl
orid
e O
R
0.9%
sod
ium
chl
orid
e +1
0% g
luco
se +
/- 20
mm
ol/L
pot
assi
um c
hlor
ide
may
be
used
w
ith e
xper
t sup
ervi
sion
.
Spec
ial C
are
Nurs
erie
s - D
AY 1
10
% g
luco
se
Spec
ial C
are
Nurs
erie
s –
DAY
2 on
war
ds
0.22
5% s
odiu
m c
hlor
ide
+ 10
% g
luco
se +
/- po
tass
ium
chl
orid
e 10
mm
ol/5
00m
L Em
erge
ncy
Depa
rtmen
ts
0.45
% s
odiu
m c
hlor
ide
+ 10
% g
luco
se (N
O p
otas
sium
chl
orid
e)
Paed
iatri
c W
ards
0.
45%
sod
ium
chl
orid
e +
10%
glu
cose
+/-
pota
ssiu
m c
hlor
ide
10m
mol
/500
mL
If
elec
troly
tes
are
outs
ide
the
norm
al ra
nge,
dis
cuss
ion
with
a s
peci
alist
is n
eces
sary
Mai
nten
ance
N
o re
com
men
datio
n (D
ay1-
3) 1
0% g
luco
se
(>3
days
) 0.2
25%
sod
ium
chl
orid
e +1
0% g
luco
se +
/- 20
mm
ol/L
pot
assi
um c
hlor
ide
OR
0.
45%
sod
ium
chl
orid
e +1
0% g
luco
se +
/- 20
mm
ol/L
pot
assi
um c
hlor
ide,
whe
re th
ere
is
pre-
exis
ting
or ri
sk o
f hyp
onat
raem
ia o
r non
-osm
otic
ADH
sec
retio
n (e
.g. p
ost-o
p,
resp
irato
ry, C
NS d
isea
ses)
.
GL2015_008 Issue date: August 2015 Page 18 of 20
Standards for Paediatric IV Fluids: NSW Health (second edition)
12.5. APPENDIX 5 – References 1. Moritz ML, Ayus JC. Prevention of Hospital-Acquired Hyponatremia: A Case for Using
Isotonic Saline. Pediatrics, 2003;111(2):227-30.
2. Neville KA, Verge CF, Rosenberg AR, O’Meara MW, Walker JL. Isotonic is better than hypotonic saline for intravenous rehydration of children with gastroenteritis: a prospective randomised study. Archives of Disease in Childhood, 2006;91(3):226-32.
3. Choong K, Kho ME, Menon K, Bohn D. Hypotonic versus isotonic saline in hospitalised children: a systematic review. Archives of Disease in Childhood, 2006;91(10):828-35.
4. Montañana PÁ, Modesto i Alapont V, Ocón AP, López PO, López Prats JL, Toledo Parreño JD. The use of isotonic fluid as maintenance therapy prevents iatrogenic hyponatremia in pediatrics: A randomized, controlled open study. Pediatric Critical Care Medicine, 2008;9(6):589-97.
5. Yung M, Keeley S. Randomised controlled trial of intravenous maintenance fluids. Journal of Paediatrics and Child Health, 2009;45(1-2):9-14.
6. Neville KA, Sandeman DJ, Rubinstein A, Henry GM, McGlynn M, Walker JL. Prevention of Hyponatremia during Maintenance Intravenous Fluid Administration: A Prospective Randomized Study of Fluid Type versus Fluid Rate. The Journal of Pediatrics, 2010;156(2):313-9.
7. Drysdale S, Coulson T, Cronin N, Manjaly Z-R, Piyasena C, North A, et al. The impact of the National Patient Safety Agency intravenous fluid alert on iatrogenic hyponatraemia in children. Eur J Pediatr, 2010;169(7):813-7.
8. Moritz M, Ayus J. Improving intravenous fluid therapy in children with gastroenteritis. Pediatr Nephrol, 2010;25(8):1383-4.
9. Moritz ML, Ayus JC. Prevention of Hospital-Acquired Hyponatremia: Do We Have the Answers? Pediatrics, 2011;128(5):980-3.
10. National Patient Safety Agency UK. Reducing the risk of hyponatraemia when administering intravenous infusions to children. Patient Safety Alert, 2007.
11. Institute for Safe Medication Practices Canada. Hospital-Acquired Acute Hyponatremia: Two Reports of Pediatric Deaths. ISMP Canada Safety Bulletin, 2009;9(7).
12. Institute for Safe Medication Practices (US). Plain D5W or hypotonic saline solutions post-op could result in acute hyponatremia and death in healthy children. Medication Safety Alert Acute Care, 2009.
13. Myburgh JA, Mythen MG. Critical Care Medicine Review: Resuscitation Fluids. N Engl J Med, 2013: 369: 1243-51.
GL2015_008 Issue date: August 2015 Page 19 of 20
Standards for Paediatric IV Fluids: NSW Health (second edition)
14. Plasma-Lyte 148 Replacement IV Infusion. Baxter Product Information 05JUL2013 http://www.baxterhealthcare.com.au/downloads/healthcare_professionals/cmi_pi/ plasmalyte148_pi.pdf
15. McNab S, Duke T, South M, Babl FE, Lee KJ, Arnup SJ, Young S, Turner H, Davidson A. 140 mmol/L of sodium versus 77 mmol/L of sodium in maintenance intravenous fluid therapy for children in hospital (PIMS): a randomised controlled double-blind trial. Lancet. 2015 Mar 28;385(9974):1190-7
16. McNab S, Ware RS, Neville KA, Choong K, Coulthard MG, Duke T, Davidson A, Dorofaeff T. Isotonic versus hypotonic solutions for maintenance intravenous fluid administration in children (Review). Cochrane Library 2014, Issue 12
17. Australian Commission on Safety and Quality in Health Care, National Recommendations for User-applied Labelling of Injectable Medicines, Fluids and Lines, 2012
18. Friedman JN, Beck CE, DeGroot J, Geary DF, Sklansky DJ, Freedman SB, Comparison of Isotonic and Hypotonic Intravenous Maintenance Fluids: A Randomized Clinical Trial, JAMA Pediatr. Published online March 09, 2015.
19. User applied Labelling of Injectable Medicines, Fluids and Lines, NSW Health (PD2012_007)
