Standards Needed for Postoperative Hydration Therapy, ISMP Says

Cheryl A. Thompson

BETHESDA, MD 13 August 2009—Investigations into the deaths of two six-year-old children have prompted the Institute for Safe Medication Practices (ISMP) to call for the establishment of standards of practice for i.v. hydration therapy in postoperative patients.

ISMP is also urging the establishment of protocols to identify, treat, and monitor patients with a low plasma concentration of sodium, water intoxication, or syndrome of inappropriate antidiuretic hormone.

According to today's issue of ISMP Medication Safety Alert!, a six-year-old girl who underwent tonsillectomy and adenoidectomy died after receiving 5% dextrose in water at 200 mL/hr for 12 hours. The postoperative orders had stated "1000 cc D5W - 600 cc q8h," but the pharmacist entered an incorrect infusion rate into the electronic medication administration record. This error was not noticed until a pediatrician, consulted by the surgeon because the girl had a grand mal seizure, recognized that the patient had signs of hyponatremia and water intoxication. The patient had had seizure-like activity earlier in the day, but the surgeon, contacted by telephone, attributed those episodes to a reaction to promethazine even though the nurses had expressed doubt.

In the other case, according to ISMP, a six-year-old boy who underwent surgery to correct a malformation in his aorta died after nurses dismissed his parents' concerns about their son becoming increasingly less responsive on the second postoperative day. The physician had prescribed an infusion of a sodium chloride solution because the boy's serum sodium concentration had dropped subsequent to treatment with diuretics. No sodium chloride infusion was documented in the medication administration record, however. The nurses attributed signs of hyponatremia to the patient receiving hydromorphone for pain relief and being "fidgety" from pain.

These fatal cases of hyponatremia, ISMP said, had two common elements: the professional staff lacked knowledge about the causes and signs of hyponatremia and did not respond to concerns expressed by others.

ISMP acknowledged that experts vary in their opinions on how to prevent and treat hyponatremia.