The issue

Although fluid and electrolytes are the most frequently prescribed drug in hospitals, prescribing practices were often suboptimal, resulting in avoidable mortalities during surgical procedures, also known as perioperative deaths.

The research

In 1999, the UK National Confidential Enquiry into Perioperative Deaths estimated that 20% of patients had either poor documentation of fluid balance or an unrecognised fluid imbalance. It also reported that a significant number of patients were dying as a result of the infusion of too much or too little fluid.

Based on this, Professor Dileep Lobo and his team undertook telephone and postal surveys of junior doctors and consultant surgeons. They found that over 90% of fluid prescription was done by the most junior member of the surgical team and that the seniors didn’t pay much attention to these prescriptions. The knowledge base was poor and there was a lot of confusion between maintenance, replacement and resuscitation requirements.

The team published a landmark clinical trial in the Lancet demonstrating that a cumulative fluid overload of as little as three litres in the first four postoperative days led to intestinal failure and increased complications. Their findings also confirmed that patients in a state of fluid imbalance have a 3.4 day longer hospital stay and a 41% greater complication rate than those maintained in a state of fluid balance.

The team’s work confirmed that the hyperchloraemia caused by saline overload can lead to a decrease in renal arterial blood flow and cortical tissue perfusion, a phenomenon demonstrated in humans for the first time.

The Impact

Professor Lobo’s research guided the formulation of the British Consensus Guidelines and NICE Guidelines on intravenous fluid therapy for adult surgical patients. It has also reduced the frequency of postoperative fluid overload, and led to improved patient outcome and potential financial benefits of £122m per year for NHS England.