Intravenous Fluid Prescription Research Articles

Appropriateness of intravenous fluid prescriptions in hospitalised patients: a point prevalence study.

Inappropriate use of intravenous (IV) fluids results in fluid overload, electrolyte disturbances, and increased costs. To describe IV fluid prescribing and its appropriateness in hospitalised patients. A point prevalence study was conducted at two sites (academic and general) of a tertiary care hospital in Belgium. All inpatients (except those in the operating theatre) and all IV fluids prescribed during a 24-h period were analysed. Data collected included type, rate and volume administered. Each IV fluid was classified by indication (i.e., resuscitation/replacement, maintenance, catheter patency management, drug administration). Appropriateness was assessed using predefined criteria and validation by attending clinicians. IV fluids were administered to 60% (297) of patients, with a median of 3 [IQR 0.5-6] IV fluid bags per patient and a median daily volume of 1000 ml [IQR 100-1550]. Amongst the 1162 IV fluid prescribed bags, 61.2% (712) were for drug administration, 22.1% (257) for catheter patency, 9.7% (112) for maintenance and 7.1% (82) for replacement/resuscitation. Inappropriate use was found for 56.9% (169) of patients with an IV fluid, representing a median volume of 300 ml per patient [IQR 10-500], and median costs of 4.60 € per patient [IQR 0.4-6.7]. Inappropriate IV fluid use is frequent in hospitalised patients, and results in significant costs. Optimisation strategies are needed.

Intravenous fluid therapy: an audit and discussion of improvements required for prescribers and administrators.

Foundation doctors and nurses are the clinicians most closely involved in fluid assessment, intravenous (IV) fluid prescription and administration. However, both groups report challenges regarding IV fluids. At a large NHS trust in England, adherence to the National Institute for Health and Care Excellence (NICE) guideline CG174, regarding IV fluids, was largely unknown. To assess the baseline adherence, within the hospitals, to CG174 and identify areas for improvement. A set of 12 audit standards were developed and used to collect data across 29 clinical areas between September 2022 and May 2023, with 255 patients receiving IV fluids at any time during their inpatient stay included. For two standards target adherence of 95% was achieved, with an adherence less than 50% in most. Areas of particularly poor adherence included assessing and meeting fluid and electrolyte requirements, patient reassessment and developing IV fluid management plans. Trust baseline adherence to NICE CG174 requires improvement, particularly regarding patient assessment and reassessment, and meeting electrolyte requirements.

Is aggressive intravenous fluid prescription the answer to reduce mortality in severe pancreatitis? The FLIP study: Fluid resuscitation in pancreatitis.

Acute pancreatitis is an emergency presentation, which can range from mild to life threatening. Intravenous fluids are the cornerstone of management. Although the WATERFALL trial described the optimal fluid rate in mild/moderate pancreatitis, this trial excluded patients with moderate-severe/severe pancreatitis. The aim of this study was to establish clinical practice regarding intravenous fluid administration in acute pancreatitis and assess its effect on mortality. Prospective multi-centre audit of patients with acute pancreatitis was conducted. Data were collected regarding intravenous fluid administration within 72 hours of admission. The primary outcome was 30-day mortality. Multivariable logistic regression was used to identify predictors of 30-day mortality. Those with severe pancreatitis received more fluid; median 5.7 L versus 4 L in 72 hours (p = 0.003). Participants with severe pancreatitis who died within 30 days received a median of 2,750 mL in the first 24 hours, compared to 4,000 mL in those who survived. The following factors were significant predictors of 30-day mortality: age, Glasgow score, C-reactive protein, ischaemic heart disease, and pancreatitis aetiology. Overall, volume of intravenous fluid was not associated with mortality. However, the effect of intravenous fluid volume on mortality differed significantly depending on pancreatitis severity. In severe pancreatitis, increased volume of intravenous fluid was associated with significant reductions in mortality (odds ratio = 0.655; 0.459-0.936; p = 0.020). In severe pancreatitis, more aggressive fluid prescription was associated with decreased mortality; however, this was not the case in milder disease. Further prospective trials guiding fluid resuscitation in severe pancreatitis are needed, as the impact of fluid on this population appears to differ from that in those with milder disease.

SP9.17 Adherence to fluid guidelines in surgical patients and impact on complication rate

Abstract Aims Up to 95% of intravenous fluid prescription requests for surgical patients are executed by Foundation Year-1(FY1) doctors. This, notwithstanding the plethora of studies suggesting FY1 doctors are inadequately equipped to be prescribing fluids unsupervised. Poor intravenous fluid therapy is associated with an approximate 20% complication rate, including electrolyte abnormalities, dysrhythmia and fluid overload. Methods A closed-loop audit was performed at a large teaching hospital to examine compliance with fluid prescribing guidelines and associated complications. This involved a 4-week retrospective review of drug prescription charts against NICE guidelines followed by a targeted intervention that involved a dedicated teaching session on fluid management in the surgical patient, alongside posters and crib sheets of fluid management on surgical wards. The re-audit using the same criteria compared proportion of prescription errors, over- or under-hydration, and total complications before and after intervention. Results 308 patient records were reviewed (pre-intervention n=185; post-intervention n=123). Documentation of fluids indication (31% vs 46%(p<0.0414)), contingency plans (3% vs 38%(p<0.0001)) and glucose prescription for nil per os patients on maintenance fluids (10% vs 25% (p=0.0029)) improved post-intervention. Fluid balance monitoring (29% vs 9%(p=0.0001)) worsened. The proportion of patients receiving insufficient potassium (91% both rounds), excess sodium (90% vs 92% (p=0.6212)), and the average rate of complications (1 in 1.67 vs 1 in 1.54, p=0.4652) remained unchanged. Conclusion Didactic educational intervention for FY1 doctors on fluid therapy improved documentation on fluids indication, but failed to resolve significant prescription failures and resulted in similar complication rates pre-and post-intervention.

ODP628 Quality Improvement Project (QIP) On Management Of Diabetic Ketoacidosis (DKA) In Adults In A District General Hospital.

Abstract Aim A Quality Improvement Project was conducted to assess if Bedford Hospital NHS Foundation Trust was meeting current Trust guidelines for the diagnosis and management of diabetic ketoacidosis (DKA) in adult patients. Method Retrospective data was collected from adult patients admitted with a diagnosis of DKA from January 2020 to December 2020. Data was collected for five key standards based on Trust guidelines: (1) Correct diagnosis of DKA, (2) Correct prescription of Intravenous (IV) fluids and potassium chloride (KCL) replacement, (3) Switching from Fixed Rate Intravenous Insulin Infusion (FRIII) to Variable Rate Intravenous Insulin Infusion (VRIII) following resolution of DKA, (4) The prescription of long-acting insulin during FRIII/VRIII and (5) Appropriate biochemical monitoring via regular venous blood gases (VBGs). Following data analysis, an intervention phase (with distribution of 'DKA diagnosis and management' posters, DKA teaching sessions and email updates on DKA management for medical doctors) was implemented. The cycle was repeated a further two times, with the most recent cycle based on patients admitted between August to November 2021. Results The first cycle consisted of 25 patients. Results showed a 72% adherence to Standard 1, a 64% adherence to Standard 3 and a 76% adherence to Standard 5. There was a notably low adherence to Trust guidelines for Standards 2 and 5, which were 32% and 12% respectively. After the intervention phases described earlier, results from the final cycle of 20 patients admitted between August to November 2021 showed significant improvement in standards 1,3 and 4 with 90%, 100% and 100% adherence to Trust guidelines respectively. Although there was a slight improvement in biochemical monitoring of patients with regular VBGs (20% adherence in the final cycle versus 12% in the first cycle), the correct prescription of IV fluids and KCL replacement remained low (17% adherence in the final cycle versus 32%). Conclusion Awareness and diagnosis of DKA remains high at Bedford Hospital, however there are issues regarding the ongoing management of DKA patients. In particular, the correct prescription of IV fluids with KCL replacement, and regular biochemical monitoring. There is still a lack of awareness as to the appropriate rate of IV fluid resuscitation, and the correct monitoring and replacement of potassium, as well as pH. Recommended changes to improve DKA management are to expand teaching sessions to include Emergency Department (ED) doctors, as well as ED and medical nursing staff, to improve awareness of the correct management and diagnosis of DKA. Further emphasis will be placed on keeping a paper copy of the Trust Adult DKA management protocol in the patients’ notes. Presentation: No date and time listed

WE3.1 Compliance of Prescription of Intravenous Fluid Resuscitation in Surgical Patients According to NICE Guidelines

Abstract Aim Assess compliance of prescription of for intravenous resuscitation fluids in accordance with NICE Guidelines in the acute surgical admissions population. Method We collected data prospectively for surgical patients admitted between 25/02/21–18/03/21 (first cycle) & 12/09/2021–4/10/2021 (2nd cycle). Maximum of 5 patients daily randomly selected. Data collected on wards after clerking on Day 1 of admission. Surgical Proforma was used to identify time of admission, presenting history and co-morbidities of patients. NEWS Charts used to identify observations of patients on admission. Drug charts used to assess volume and types of intravenous fluids prescribed. Admissions by audit authors were excluded to prevent selection bias. Intervention Posters in Emergency Assessment Unit and Wards, Teaching to junior doctors, Regular reminder messages to on-call teams. Results 72 patients included in audit. Prescription of Intravenous resuscitation fluids in Acute Surgical Patients in compliance with NICE guidelines rose from 49% to 69% between cycle 1 and 2, respectively. Correct prescriptions in volume and type of fluid rose from 2% (cycle 1) to 44% (cycle 2). Conclusions Almost one third of acute admissions met the criteria for resuscitation IV fluids. In indicated patients, nearly one half of patients were correctly prescribed resuscitation fluids in accordance with guidelines.

EP-343 Compliance of Prescription of Intravenous Maintenance Fluids in Acute Surgical Patients According to NICE Guidelines

Abstract Aim Assess compliance of prescription of for intravenous maintenance fluids in accordance with NICE Guidelines in the acute surgical admissions population. Method Total of 158 patients were included. We collected data prospectively for surgical patients admitted between 25/02/21–18/03/21 (first cycle) & 12/09/2021–4/10/2021 (2nd cycle). Maximum of 5 patients daily randomly selected. Data collected in wards after clerking on Day 1 of admission. Surgical Proforma was used to identify feeding plan for patients. Drug charts used to assess volume and types of intravenous fluids prescribed. Admissions by audit authors were excluded to prevent selection bias. Intervention Posters in Emergency Assessment Unit and Wards, Teaching to junior doctors, Regular reminder messages to on-call teams. Results Prescription of Intravenous Maintenance Fluids in Acute Surgical Patients in compliance with NICE guidelines for IV Fluid maintenance rose from 6% to 22% between cycle 1 and 2, respectively. In non-compliant prescriptions, the issue was due to excess volume (73%), sodium and chloride (88%) as well as inadequate potassium (75%) and glucose (40%). Conclusions Most acute surgical admissions require maintenance fluids. Some patients did not have their weight recorded which is necessary for correct calculation of fluid requirements. Some patients were prescribed maintenance fluids although they were not indicated. Most patients received an excessive fluid volume, sodium & chloride. Most patients received inadequate potassium & glucose. Ward based nursing staff are reluctant to give maintenance fluids containing potassium. More teaching and awareness on correct prescription of maintenance fluids is needed.

Intravenous fluid therapy: a multi-national, cross-sectional survey of common medical student resources

BackgroundInappropriate prescription of intravenous fluid therapy is highly prevalent in hospitals, with up to 1 in 5 patients suffering from preventable, additional morbidity. Since trainee physicians are frequently responsible for prescribing intravenous fluids, it is possible that common medical student resources do not sufficiently cover the topic. There is a paucity of recent literature on this issue, which this study was designed to address.MethodsTwo original evaluation tools were created by the authors to evaluate reference books, official guidelines, and online reference sources commonly used by medical students in the United States of America, Australia, and the United Kingdom on their coverage of foundational and clinically relevant principles of intravenous fluid prescription. The choice of student resources was guided by a literature search and personal experience. A total of 10 resources was assessed.ResultsResources were generally deficit in their coverage of basic intravenous fluid topics. The total points each topic accumulated ranged from 0.5 (5%) to 7.5 (75%), with the median score being 4.5 (45%), on a scale from 0 to 10 points.ConclusionsPopular medical student resources poorly cover intravenous fluid therapy topics. This may be contributing to inadequate fluid prescribing practices.

Brief Report: Intravenous fluid prescribing and complications in children in the UK and Ireland.

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129 Compliance with The ERAS Protocol Amongst Colorectal Surgery Junior Doctors at Gloucester Royal Hospital

Abstract Background Enhanced recovery after surgery (ERAS) is an evidence-based protocol aiming to expedite recovery following elective surgical procedures. ERAS has shown to reduce the length of hospital stay, complications, readmissions, and costs. The junior doctor’s role in ERAS centres around admission, preoperative nutritional care, and ERAS compliance. This audit aimed to review prescribing of perioperative nutritional drinks (NutriciaPreop© and Fortisips) and intravenous fluids for patients undergoing elective colorectal surgery at Gloucester Royal Hospital. Method An 80% standard was set for this audit. A full audit cycle was completed. Drug and intravenous fluid charts were analysed for correct prescribing of NutriciaPreop© and intravenous fluids pre-operatively, and peri operative Fortisips. Improvement measures included ward posters and education to incoming junior doctors. Results Initial data collection showed that 70% of patients received a correct intravenous fluid prescription pre-operatively. 24% of patients were prescribed NutriciaPreop© and 18% were prescribed Fortisips. During re-auditing intravenous fluids were correctly prescribed in 80% of patients, NutriciaPreop© in 67% of patients and Fortisips in 60%. Conclusions This audit emphasises the importance of good quality inductions for junior doctors and how simple measures improve prescribing of essential peri-operative nutrition. Additionally, the value of multidisciplinary team involvement in junior doctor training has been highlighted.

Initial intravenous fluid prescription in general paediatric in-patients aged >28 days and

Initial intravenous fluid prescription in general paediatric in-patients aged >28 days and <18 years: consensus statements.

From hypotonic maintenance fluid to severe hyponatremia: a case report

BackgroundThe principles for maintenance intravenous fluid prescription in children were developed in the 1950s. These guidelines based on the use of hypotonic solutions have been challenged regularly for they seem to be associated with an increased risk of hospital-acquired hyponatremia.Case presentationWe report the case of a 4-week-old Caucasian child admitted for acute bronchiolitis who received hypotonic maintenance fluids and developed severe hyponatremia (94 mmol/L) with hyponatremic encephalopathy.ConclusionThis clinical situation can serve as a reminder of the latest recommendations from the American Academy of Pediatrics regarding the use of intravenous fluids that promote the use of isotonic fluids in children.

Does the Implementation of a Clinical Care Pathway Have an Impact on Early Intravenous Fluid Therapy of Acute Pancreatitis?: A Pilot Quality Improvement Study.

Early intravenous fluid (IVF) resuscitation is crucial in the management of acute pancreatitis; variation in IVF prescription practice had been demonstrated. This pilot study aims to assess whether the implementation of an Acute Pancreatitis Care Pathway (APCP) produces a change toward a more adequate IVF regimen in the first 24 hours. Patients with confirmed diagnosis of acute pancreatitis, from July 2015 to February 2016 (group 1) and from September 2017 to March 2018 (group 2), were considered. The APCP was developed between March 2016 and August 2017. Median IVF rate, volume, and type infused in the first 24 hours, were compared between groups. Nonparametric data were analyzed with the Mann-Whitney U test, differences in frequencies with the McNemar test; significance was set at P < 0.05. Seventy-two patients were included, 36 in each group. In the first 24 hours, the median IVF rate was 177 mL/h vs 225 mL/h (P = 0.004); Ringer lactate infusion was 30% vs 77.8% (P = 0.0003). The median total IVF volume did not differ between groups. The implementation of the APCP has the potential to lead to a successful change in early IVF resuscitation practice.

Does the implementation of a clinical care pathway have an impact on early intravenous fluid therapy of acute pancreatitis? a pilot quality improvement study

Objectives Early intravenous fluid (IVF) resuscitation is crucial in the management of acute pancreatitis; variation in IVF prescription practice had been demonstrated. This pilot study aims to assess whether the implementation of an Acute Pancreatitis Care Pathway (APCP) produces a change toward a more adequate IVF regimen in the first 24 hours. Methods Patients with confirmed diagnosis of acute pancreatitis, from July 2015 to February 2016 (group 1) and from September 2017 to March 2018 (group 2), were considered. The APCP was developed between March 2016 and August 2017. Median IVF rate, volume, and type infused in the first 24 hours, were compared between groups. Nonparametric data were analyzed with the Mann-Whitney U test, differences in frequencies with the McNemar test; significance was set at P Results Seventy-two patients were included, 36 in each group. In the first 24 hours, the median IVF rate was 177 mL/h vs 225 mL/h (P = 0.004); Ringer lactate infusion was 30% vs 77.8% (P = 0.0003). The median total IVF volume did not differ between groups. Conclusions The implementation of the APCP has the potential to lead to a successful change in early IVF resuscitation practice.

Study of prescription of injectable drugs and intravenous fluids to inpatients in a teaching hospital in Western Nepal

Unnecessary, excessive and poor injection practices in the South East Asia region (including Nepal) have been observed previously. The authors aim to study prescription of injectable drugs to inpatients in a teaching hospital in Western Nepal. Prescription of injectable drugs (IDs) and intravenous fluids (IVFs) to inpatients discharged from the wards of the Manipal Teaching Hospital during 1st January to 30th June 2006 was studied. The mean number of drugs, IDs and IVFs administered, median cost of drugs and of IDs/IVFs per prescription calculated. Comparison of ID/IVF use in the four major hospital departments (Medicine, Obstetrics and Gynecology, Pediatrics and Surgery) was done. The administration of IDs/IVFs and injectable antimicrobials were measured in Defined Daily Dose (DDD)/100 bed-days and of Intravenous fluid in Liters (L)/100 bed-days. Of the 1131 patients discharged, 938 (82.94%) patients received one or more IDs/IVFs. The mean number of drugs, IDs and IVFs prescribed were 8.75, 4.72 and 1.42. Median cost of drugs and IDs/IVFs per prescription were 8.26US$ and 5.12US$ respectively. IDs/IVFs accounted for 81.37% of total drug cost. The most commonly used ID, injectable antimicrobial and IVF were Diclofenac (19.3 DDD/100 bed-days), Metronidazole (7.68 DDD/100 bed-days) and Dextrose normal saline (8.56 L/100 bed-days), respectively. The total IVF consumption was 24.25 L/100 bed-days. Significant differences between departments were observed (p<0.05). In conclusion, the use of IDs/IVFs was higher compared to other studies. Interventions to improve IDs/IVFs prescribing practices may be required.

Understanding Volume Kinetics: The Role of Pharmacokinetic Modeling and Analysis in Fluid Therapy.

Fluid therapy is a rapidly evolving yet imprecise clinical practice based upon broad assumptions, species-to-species extrapolations, obsolete experimental evidence, and individual preferences. Although widely recognized as a mainstay therapy in human and veterinary medicine, fluid therapy is not always benign and can cause significant harm through fluid overload, which increases patient morbidity and mortality. As with other pharmaceutical substances, fluids exert physiological effects when introduced into the body and therefore should be considered as “drugs.” In human medicine, an innovative adaptation of pharmacokinetic analysis for intravenous fluids known as volume kinetics using serial hemoglobin dilution and urine output has been developed, refined, and investigated extensively for over two decades. Intravenous fluids can now be studied like pharmaceutical drugs, leading to improved understanding of their distribution, elimination, volume effect, efficacy, and half-life (duration of effect) under various physiologic conditions, making evidence-based approaches to fluid therapy possible. This review article introduces the basic concepts of volume kinetics, its current use in human and animal research, as well as its potential and limitations as a research tool for fluid therapy research in veterinary medicine. With limited evidence to support our current fluid administration practices in veterinary medicine, a greater understanding of volume kinetics and body water physiology in veterinary species would ideally provide some evidence-based support for safer and more effective intravenous fluid prescriptions in veterinary patients.

Postoperative outcomes based on crystalloid administration in pediatric patients with necrotizing enterocolitis undergoing laparotomy

Intravenous fluid prescription is an essential part of postoperative care and may play a causal role in postoperative complications. The objective of the present study was to evaluate the relationship between intraoperative fluid administration and postoperative outcomes in a large cohort of pediatric patients.This analysis included a retrospective review of 172 patients who underwent gastroenterological surgery from January 2012 to September 2018 at an academic tertiary care hospital. Patients were evaluated based on the median amount of corrected crystalloids and subsequently dichotomized as low (<25.89 mL/kg h) versus high (>25.89 mL/kg h). The primary outcome measure was the postoperative length of hospital stay (pLOS). Secondary outcome measures included the postoperative time to restore gastroenterological functions and postoperative complications.Patients who received larger amounts of crystalloids were more likely to have a lower intraoperative level of hemoglobin (P = .78) and an intraoperative blood transfusion (P = .27). There were trends toward lower incidence rates of hyperchloremic acidosis (P = .375) and metabolic acidosis (P = .54) in the high crystalloid administration cohort. The incidence of postoperative complications increased as the amount of administered fluid decreased (P = .046). The total length of hospital stay was shorter in patients who received high volumes of crystalloid fluid (19.5 [15.75–32.25] days) than in patients who received low volumes (22 [16–29.5] days, P = .283).Significant and multifaceted variability in crystalloid administration was noted among pediatric patients undergoing major surgery. High fluid administration was associated with favorable postoperative outcomes; these findings could be applied to improve patient safety and facilitate better quality of care.

An ethnographic exploration of diarrheal disease management in public hospitals in Bangladesh: From problems to solutions

Diarrheal disease is one of the most common causes of hospital admission globally. The barriers that influence guideline-adherent care at resource limited hospitals are poorly defined, especially during diarrheal disease outbreaks. The objective of this study was to characterize challenges faced in diarrheal disease management in resource-limited hospitals and identify opportunities to improve care. The study was conducted during a diarrheal disease outbreak period at ten public district hospitals distributed across Bangladesh. A rapid ethnographic approach included observations and informal interviews with clinicians, staff nurses and patients. In the first phase, observations identified common and unique challenges in diarrheal management at the ten sites. In the second phase, four hospitals were purposively selected for additional ethnographic study. Systematic observations over 420 total hours were collected from patient-clinician interactions (n=76) and informal interviews (n=138). Applied thematic analysis identified factors that influenced hospitalbased diarrhea management. Normalization of guideline deviation was observed at all ten sites, including prescription of non-indicated antibiotics and intravenous (IV) fluids. Conflict between 'what should be done' and 'what can be done' was the most common challenge identified. Clinical assessments and patient treatment plans were established at admission in a median of 2minutes (n=76), often without a physical examination (57%; n=43/76). Factors that prevented adherence to clinical guidelines included human resource constraints, conflicts of interests, overcrowding, and inadequate hygiene and sanitation in the emergency department and wards. This study identified challenges in hospital-based management of diarrheal disease and opportunities to improve care in seemingly change-resilient hospital settings. The results reveal important areas for intervention and policy engagement that may have additive benefit for both hospitals and their patients. These interventions include targeting barriers to clean-water, sanitation and hygiene that prevent clinicians from adopting guidelines out of concern for hospital acquired infections.

Fluid Abuse Following Minor to Intermediate Elective Surgeries

Background: The restriction to the guidelines for postoperative management (as omission of routine use of nasogastric tubes, early institution of oral feeding and mobilization and clarified indications of administration of intravenous fluids) has resulted in a decrease in perioperative intravenous fluid administration in fast-track surgical programs (in particular day case surgeries). In minor to intermediate surgeries, shifting of perioperative fluids are small and organ dysfunctions are minimum. Objective: To establish fluid abuse postoperatively following minor and intermediate surgeries. Patients and Methods: This is a prospective study done in Iraq-Diyala-Baquba teaching hospital over a period of one year from January 2018 – January 2019.The case sheets of 640 elective surgical cases had been reviewed for the intravenous fluid prescription after surgery. The types of surgeries reviewed were those which theoretically based, do not need postoperative intravenous fluid administration or shouldn’t be given for more than few hours; but should start early oral fluid. The emergency cases were excluded from this study. The data collected from the case sheets of different elective surgeries in the surgical ward. The 640 patients who underwent elective mild to intermediate surgeries. Results: Of those who underwent surgeries under general anesthesia, it has been found that 288 out of 390 patients (90%) were given intravenous fluid postoperatively for a period from 8- 24 hours. Of those who underwent surgeries under spinal anesthesia, it has been found that 134 out of 174 patients (77%) patients were given intravenous fluid postoperatively for a period from 8- 12 hours. Of those who underwent surgeries under local anesthesia, it has been found that 36 out of 76 patients (47%) were given intravenous fluid postoperatively for a period from 8- 12 hours. The volume of fluid prescribed ranged from 500ml to 2 liters. Conclusion: Routine prescription of intravenous fluids following minor to intermediate surgeries is theoretically unsupported and is unnecessary most of the time as far as the patient is maintained well hydrated intraoperatively.

Regular performance feedback may be key to maintain good quality DKA management: results from a five-year study

ObjectivesWe postulate that performance feedback is a prerequisite to ensure sustained improvement in diabetic ketoacidosis (DKA) management.DesignThe study was based on ‘theory of change’ concept that suggests changes of primary...