Authors of guideline respond

Dear Sir,

Intravenous (IV) fluid prescribing is one of the primary roles of the
foundation year 1 (FY1) doctor. Despite this, 15% of consultants feel FY1
doctors are ill-equipped to prescribe IV fluids safely [1]. There is also
evidence to suggest that FY1 doctors lack knowledge and confidence when
undertaking this important task [2].

In 2008, The British Consensus Guidelines on Intravenous Fluid
Therapy for Adult Surgical Patients (GIFTASUP) were developed [3]. They
provide recommendations on IV fluid prescribing in the pre-operative as
well as the postoperative period. They also make suggestions on patient
parameters that should be used when assessing the fluid status of a
surgical patient.

With this in mind we undertook a questionnaire study looking at the
knowledge and confidence along with the use of GIFTASUP guidelines in 33
FY1 doctors in their first post of FY1. General knowledge regarding IV
fluid preparations and clinical application was very poor before with
nearly half 16 (48.5%) scoring only 2/5, 5 (15.2%) 3/5 and 2 (6.1%) 4/5.
Confidence was poor with majority of doctors giving 3/5 for prescribing IV
fluids, fluid challenge and adding potassium to a fluid regimen (52%, 52%
and 46% respectively).

We found that clinical parameters suggested by GIFTASUP to assess
patients fluid status are poorly utilised by junior medical staff. Of
interest, only pulse, blood pressure and urine output (79%, 85% and 88%
respectively) were used on a regular basis. Disappointingly, only half of
the doctors stated that they used blood results, co-morbidities, volume of
fluid previously prescribed, JVP and how the patient looks, to help them
prescribe IV fluids.

This study has formally demonstrated what many senior doctors have
observed for some time: that FY1 doctors in their first post have an
alarmingly poor understanding of the content of the various intravenous
fluids commonly prescribed in surgical patients and the indications for
using different fluid regimens. Although these findings have been
reported previously, the deficiencies remain and might explain the
incidence of fluid overload and iatrogenic pulmonary oedema in surgical
patients [2,4,5]. The results from this study reflect badly on
undergraduate medical education and as the FY1 doctors came from a variety
of Medical Schools this problem is likely to be widespread. The
importance of understanding the physiological changes around various
clinical states and the implications for IV fluid prescribing practice
must assume greater importance in both undergraduate and postgraduate
medical education.

1. Lobo, D. N., Dube, M. G., Neal, K. R., Allison, S. P. &
Rowlands, B. J. (2002) Peri-operative fluids and electrolyte management: a
survey of consultant surgeons in the UK. Annals of the Royal College of
Surgeons of England, 84:156-160.

2. Lobo DN, Dube MG, Neal KR, Simpson J, Rowlands BJ, Allison SP.
Problems with solutions: drowning in the brine of an inadequate knowledge
base. Clin Nutr 2001;20: 125-130.

3. Powell-Tuck J, Gosling P, Lobo DN, Allison SP, Carlson GL, Gore M,
et al. British Consensus Guidelines on Intravenous Fluid Therapy for Adult
Surgical Patients - GIFTASUP. 2008. Available from:
http://www.ics.ac.uk/intensive_care_professional/british_consensus_guide...

4. Walsh S. R.; Walsh C. J. Intravenous fluid-associated morbidity in
postoperative patients. Annals of the Royal College of Surgeons of
England 2005, 87(2):126-130

5. Lowell JA, Schifferdecker C, Driscoll DF, Benotti BN, Bistrian BR.
Postoperative fluid overload: not a benign problem. Crit Care Med 1990;
18: 728-33.