Background: Complex fluid balance problems are well established post-neurosurgery and traumatic brain injury (TBI). The triple-phase response requires fluid management strategies reactive to urine output as patients shift between DI and SIADH. Prevalence of CSW is controversial; but ensuring sodium homeostasis is central to safe fluid management. To improve clinical care for these complex patients an audit of existing institutional guidelines was undertaken. New guidelines were developed with structured educational packages for specialist teams involved, and subsequent assessment of their impact.
Method: Two periods were audited using set standards (table-1), before and after the quality improvements. All data was collected from the CQUIN neurosurgical database and electronic medical records; included were all paediatric patients having neurosurgical operations for posterior fossa (PFT) and supratentorial tumours (STT), plus TBI. A literature review of evidence-based practice, initial audit data and stakeholder feedback was used to develop new clinical guidelines and nursing standard operating procedures. Principles were of strict monitoring and adaptive fluid management strategies, implemented for all with active step down. Structured educational packages were designed for specialty medical and nursing teams involved to improve knowledge, consistency of approach and team working.
Results: Audit-1 January2017-June2018, n=80; Audit-2 January2020-June2021, n=30 (reduced neurosurgical operation numbers due to COVID-19 pandemic). All patients were managed within a high dependency setting; 26-33% initially in paediatric intensive care. Step-down was to a neurosurgical/neurorehabilitation ward. Results comparison (table-1) demonstrated clinical, fluid balance and biochemical monitoring improvement. The number of clear fluid management plans documented post-operatively increased, leading to early recognition and management of evolving fluid-balance abnormalities. However, the recommended adaptive fluid management strategy was not always used. The endocrine team were involved earlier and in all complex cases. Significant Na fluctuations (>12mmol in 24 hours) remained similar (5vs6patients). These represented complex pituitary-hypothalamic pathology, plus one TBI. Feedback from patients and professional teams was of increased awareness, improved consistency of approach and communication.
|Complete fluid balance charts||51%||77%||0.063|
|Fluid management plan post-op||64%||71%||0.7813|
|Endocrine team Involvement||14%||35%||0.0735|
|DDAVP prescription with endocrine team||60%||100%||0.444|
Conclusion: • Clinical guidelines revised using audited data, evidence-based literature review and stakeholder consultation have been adopted with effective change.
• Patient safety improved through effective post-neurosurgical fluid management and multi-professional team working.
• Regular feedback and continued education will identify areas for further improvement.
15 Sep 2022 - 17 Sep 2022