(87) Impact of Implementing a Guide on Intravenous Fluids to Minimise the Risk of Hospital-Acquired Hyponatraemia in Denmark

Publication Number: 418

Background: The European Medicines Agency's Pharmacovigilance Risk Assessment Committee concluded in 2017 that hypotonic intravenous (IV) fluids are associated with an increased risk of hospital-acquired hyponatraemia (HAH) eventually leading to brain injury and death.

Objectives: To evaluate the effectiveness of a treatment guide implemented in Denmark as part of risk minimisation measures to reduce the risk of hospital-acquired hyponatraemia.

Methods: We conducted a cross-sectional survey, including a pre-measurement (spring 2019) preceding the distribution of the treatment guide (June 2020) and a post-measurement (June 2021). Prescribing practices of IV fluids were assessed by means of four clinical scenarios commonly encountered in the emergency department. Eight multiple-choice questions were used to measure knowledge about IV fluids and hyponatraemia. A priori we defined an absolute success criterion as a risk of being treated incorrectly with hypotonic fluids by no more than 10% of prescribers in each scenario. For the knowledge measure we used a pre-defined threshold of success of 80% correct answers. Chi square test was used to compare prescribing practice before and after the implementation of the treatment guide.

Results: After the intervention, about a third (30.5%) reported that they would use hypotonic fluids in patients with increased intracranial pressure, and a quarter (25.3%) would use hypotonic maintenance fluids in children, both of which are against guideline recommendations. About 6% reported to use hypotonic fluids in patients with hypovolaemia without severe symptoms of hyponatraemia and 7.1% would use hypotonic fluids in patients with severe symptoms of hyponatraemia. Significant improvement was only seen for use of hypotonic fluids in patients with severe symptoms of hyponatraemia, which decreased from 16.5 to 7.1% (p < 0.05). For all scenarios together, 20.3% and 17.2% incorrectly selected a hypotonic fluid pre- and post-intervention, respectively. None of the knowledge questions met the predefined criteria of success at 80% correct answers (range 10.8% - 77.6). 21.5% of respondents received the treatment guide and 16.9% read it.

Conclusions: Use of hypotonic fluids against guideline recommendations is widespread and calls for further interventions to reduce the risk of hospital-acquired hyponatraemia. Implementation of the treatment guide was unsuccessful and therefore does not allow for any conclusion of the intervention on prescribing practice.