Reducing the risk of hyponatraemia when administering intravenous infusions to children

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.

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 fluids to children. 

  (BMJ learning website - free registration required)