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Reducing the risk of hyponatraemia when administering intravenous infusions to children

Reducing the risk of hyponatraemia
Reference number
0409
Central Alert System (CAS) reference
NPSA/2007/22
Issue date28 March 2007
Action date (if applicable) (date field)30 September 2007
DH Gateway reference
7738
TypeAlert

This Patient Safety Alert advises to healthcare organisations how to minimise the risks associated with administering intravenous infusions to children.

 

The development of fluid-induced hyponatraemia (a plasma sodium of less than 135mmol/L) in the previously well child undergoing elective surgery or with mild illness may not be well recognised by clinicians.

 

Since 2000, there have been four child deaths (and one near miss) following neurological injury from hospital-acquired hyponatraemia reported in the UK. International literature cites more than 50 cases of serious injury or child death from the same cause, and associated with the administration of hypotonic infusions.

 

Healthcare organisations should take the following actions:

 

  1. Remove sodium chloride 0.18% with glucose 4% intravenous infusions from stock and general use in areas that treat children. Suitable alternatives must be available. Restrict availability of these intravenous infusions to critical care and specialist wards.
  2. Produce and disseminate clinical guidelines for the fluid management of paediatric patients.
  3. Provide adequate staff training and supervision. 
  4. Review and improve the design of existing intravenous fluid prescriptions and fluid balance charts for children.
  5. Promote the reporting of hospital-acquired hyponatraemia incidents via local risk management reporting systems. Implement an audit programme.

 

Notes

Although the deadline for actions has passed, this guidance remains best practice. It should be followed to prevent future patient safety incidents.

 

 

Related guidance from The National Institute for Health and Clinical Excellence (NICE)

In June 2010, NICE published guidance on the management of bacterial meningitis and meningococcal septicaemia in children and young people younger than 16 years in primary and secondary care.

 

This guidance contains recommendations on the use of fluids for bacterial meningitis and intravenous fluid resuscitation in meningococcal septicaemia. The NICE clinical guideline makes recommendations specifically related to the use of intravenous fluids in children with raised intracranial pressure and increased antidiuretic hormone secretion.

 

E-learning module

The NRLS has commissioned a free e-learning module to support staff training.

 

 

 

Reducing the risk of hyponatraemia when administering intravenous infusions to children - Patient Sa
Reducing the risk of hyponatraemia when administering intravenous infusions to children - Patient Sa - 401 KB 0409 - Reducing the risk of hyponatraemia when administering intravenous infusions to children - Patient Safety Alert - 2007-03-28 - V1
Treating children safely when giving fluids by injection - Patient Briefing
Treating children safely when giving fluids by injection - Patient Briefing - 115 KB 0409A - Treating children safely when giving fluids by injection - Patient Briefing - 2007-03-28 - V1 - CY
Treating children safely when giving fluids by injection - Patient Briefing
Treating children safely when giving fluids by injection - Patient Briefing - 75 KB 0409A - Treating children safely when giving fluids by injection - Patient Briefing - 2007-03-28 - V1
Hyponatraemia - Background information
Hyponatraemia - Background information - 180 KB 0409B - Hyponatraemia - Background information - 2007-03-28 - V1
Prescribing intravenous fluids for administration to children - Workforce competence statement
Prescribing intravenous fluids for administration to children - Workforce competence statement - 184 KB 0409C - Prescribing intravenous fluids for administration to children - Workforce competence statement - 2007-03 - V1
Hyponatraemia paediatric audit checklist
Hyponatraemia paediatric audit checklist - 134 KB 0409 D | Hyponatraemia paediatric audit checklist | Alert 22 | 2007-03-28