Pharmacists’ recommendations for fluid minimisation in critically ill patients

Abstract

Background: Effective fluid management is essential to reduce the risk of fluid overload, which is associated with worse outcomes in critically ill patients. Intravenous fluids, including hidden fluids, are necessary and frequently used in the intensive care unit (ICU).1 Aim: To assess pharmacists’ interventions related to minimising hidden fluids for patients admitted to the ICU and evaluate the significance of these interventions in their ability to prevent potential adverse drug events (ADEs). Method: The research was conducted during three months in a mixed ICU of an acute general hospital, where clinical pharmacists participate in ward rounds as members of the multidisciplinary team. Recommendations made by pharmacists related to fluid minimisation were compiled. In collaboration with ICU physicians and nurses, the pharmacists suggested fluid minimisation interventions depending on clinical indication and the amount of hidden fluids being administered. The data was classified into the type of intervention, and was evaluated for potential prevention of an adverse drug event (ADE) by an expert panel of healthcare professionals. Results: Pharmacists intervened in minimising hidden fluids for 17 patients (10%) out of 164 patients admitted to the ICU over the three months. Fluid minimisation was required in patients with heart failure and pulmonary oedema, patients with severe renal impairment, patients with brain injury necessitating a neutral fluid balance, and patients with respiratory distress syndrome requiring a conservative fluid strategy to improve lung function, amongst others. Several interventions were recommended by pharmacists for each patient to reduce the total fluid intake, involving multiple medications. These included concentrating infusions when administering via a central venous catheter for all patients (n = 17), opting for a more fluid-restricted enteral feed (n = 5), and converting medications from intravenous to enteral route (n = 3). The recommendations successfully reduced fluid intake by 700 mL over 24 h for a patient with heart failure, and 820 mL over 24 h for a patient with a brain injury. The expert panel found these interventions had a medium probability (77%) or low probability (23%) of preventing a potential ADE. Conclusion: This study highlights the importance of pharmaceutical recommendations in targeted fluid minimisation strategies. The pharmacists' interventions to reduce hidden fluid in specific critically ill patients helped mitigate fluid overload and prevent potential ADEs in this patient group.