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Practice Guidelines

Intravenous fluid therapy for adults in hospital: summary of NICE guidance

BMJ 2013; 347 doi: (Published 10 December 2013) Cite this as: BMJ 2013;347:f7073

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Re: Intravenous fluid therapy for adults in hospital: summary of NICE guidance

Dear Editor,

This latest piece of NICE guidance is clearly useful - intravenous fluids are obviously not being correctly used all the time - but I do feel there is an element of sensationalism around the claim that 'as 1 in 5 patients on IV fluids and electrolytes suffer complications' reported in the press release and the BMJ review of this guidance.

I am not entirely sure where this figure has come from. The NICE authors reference three NCEPOD reports for this figure, from 1999, 2010, and 2011.

The NCEPOD report in 1999 (1)states that 20% of elderly patients had "either poor documentation of fluid balance or unrecognised/untreated fluid imbalance" (1) but as far as I can see makes no comment on any extra morbidity this may cause.

The 2011(2) report has more figures. There were 829 patients included, although some were only partially included as there was subtotal data. Of these, 529 patients had their preoperative fluid status examined. 527 of them had 'adequate' fluid resuscitation - 92.6%. In the group that had inadequate fluid resuscitation, there was a significant increase in mortality (20.5% to 4.7%), although we have no account of confounding factors (were they sicker patients?).

The 2010 (3) report is about patients on paraenteral nutrition. This is a very small number of patients on intravenous fluid, with complex needs. Clearly, these patients need specialist input and may well get the wrong amounts of fluids, especially if managed on a general ward. However, i'm not sure this can be generalized to other fluid prescriptions.

Fluid prescribing and monitoring is hard, especially in sick patients, and more training is clearly needed, which I thank the guidance for.

However, inappropriate use of figures is not helpful, and sensationalises what is a complex, multifactorial issue.

1) NCEPOD. Extremes of age: the 1999 report of the National Confidential Enquiry into Perioperative Deaths. 17 Nov 1999.

2) NCEPOD: Knowing the Risk: A Review of the Perioperative Care of Surgical Patients. London: NCEPOD; 2011.

3) NCEPOD. A Mixed Bag: The 2010 report of the National Confidential Enquiry into Parenteral Nutrition. London: NCEPOD, 2010.

Competing interests: None declared

Competing interests: No competing interests

12 December 2013
Fergus W Hamilton
F2 Doctor
UHBristol / University of Bristol
Bristol Royal Infirmary, Upper Maudlin Street, BS2 8HW