ESPE Abstracts (2022) 95 P1-547

ESPE2022 Poster Category 1 Pituitary, Neuroendocrinology and Puberty (77 abstracts)

Project to improve paediatric post-neurosurgical fluid management and to reduce the risks associated with Diabetes Insipidus (DI), Syndrome of Inappropriate ADH (SIADH) and Cerebral Salt Wasting (CSW).

Felix Miller-Molloy 1 , Shreya Saxena 2 , Philippa Bowen 3 , Greg Fellows 3 & Liz Crowne 3

1University of Bristol, Bristol, United Kingdom; 2Royal London hospital, Bart's NHS trust, London, United Kingdom; 3Bristol Royal Hospital for Children, Bristol, United Kingdom

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.

Table 1
Standard Audit-1 Audit-2 Fisher's test
Complete fluid balance charts 51% 77% 0.063
Fluid management plan post-op 64% 71% 0.7813
Electrolytes post-op 78% 94% 0.1816
Electrolytes 4-8hrly 18% 35% 0.1848
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.

Volume 95

60th Annual ESPE (ESPE 2022)

Rome, Italy
15 Sep 2022 - 17 Sep 2022

European Society for Paediatric Endocrinology 

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