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FLUID THERAPY PRESCRIBING ON THE MEDICAL ADMISSIONS UNIT
Elsayed, I¹, Dean, W², James, M², Mofidi, S²
¹Sheffield Kidney Institute, ²Medical Admissions Unit, Northern General Hospital,
Sheffield
INTRODUCTION: Acute kidney injury (AKI) is common in hospitalised patients and is
associated with poor prognosis. In patients with AKI and multi-organ failure (MOF) on
intensive care units (ICU) mortality can reach up to 80%. Only 50% of patients who died in
hospital with AKI received an overall good standard of care, of the remainder poor clinical
care rather than organizational issues were at fault, found the NCEPOD report in 2009. AKI
was most frequently due to hypovolaemia or dehydration either in isolation or with another
diagnosis.
The Renal Association Guideline on AKI management stresses the need for volume status
assessment and appropriate fluid therapy.
AIM: To estimate the proportion of patients with AKI who had their volume status assessed
at presentation and whether or not fluid therapy was prescribed appropriately, on the medical
admissions unit.
METHODS: We collected prospective data on patients admitted to the acute medical
admissions unit with evidence of AKI during the month of August 2012. The Kidney Disease:
Improving Global Outcomes (KDIGO) definition and staging classification of AKI were used
to identify these patients.
We collected the following data: the presence or absence of volume status assessment, the
type of fluids prescribed on the first three days of hospitalisation & the training grade of the
prescribing doctor.
RESULTS: We identified 18 patients using the KDIGO definition. None of the patients had
their volume status assessment documented in the medical notes. 28% of the fluids were
prescribed by Foundation Year 1 doctors & 72% by Foundation Year 2-Core Training year 2
doctors. The main type of intravenous (IV) fluid prescribed was 0.9% Saline, constituting
82% of the fluids prescribed on the first two days & 56% of the fluids prescribed on the third
day.
DISCUSSION: Central to successful management of AKI is cautious assessment of volume
status and appropriate treatment of fluid deficits. There is no evidence favouring certain
crystalloid fluid usage in cases of AKI, making appropriate prescription challenging for junior
doctors. Inadequate knowledge of fluid management was to blame for many of the deaths
reported by NCEPOD. 14% of patients had AKI that could have been avoided if patients had
been adequately hydrated, yet previous surveys and audits, as well as our results, have shown
that fluid prescription is generally undertaken by junior doctors. The intricacies of
management, combined with the high mortality ascribed to AKI, should make appropriate
education of junior doctors on both assessment of volume status and subsequent prescription
of IV fluids a priority.
CONCLUSION:
 Principles of fluid therapy, including composition of different fluids, have to be
incorporated in the formal training of junior doctors.

Well designed, adequately powered studies are required to add and improve on the
evidence available to support the use of different fluids.

National standards are needed for guiding prescription of fluids in the acutely unwell
patient.