Fluid & Elecrolytes Management in Newborns

Fluid & Elecrolytes Management In Newborns

DR.MAULIK SHAH MD.(PED)ASSOCIATE PROFESSOR OF PEDIATRICS

M.P.SHAH MEDICAL COLLEGE,JAMNAGAR.

vessel

cell interstitium cellINTRA CELLULAR fluid

EXTR

A CE

LLU

LAR

fluid

vesselcell interstitium

EXTRA CELLULAR fluidINTRA CELLULAR fluid

0 3 6 9 // 0 3 6 9 0

20

40

60

80

10092%

77%

66%60%60%

45%

26%

30%

42%36%32%

26%

Age in months

Fetus

N e w- B o r nB

o d

y W

a t

e r c

o n

t e

n t

%

TBW

ECW

ICW

TBW……ECF…..ICF

Changes during delivery & labour

vessel

cell interstitium cell

Why Newborn / preterm babies have large amount of water than older

infants ?

Why Preterm babies loose more wt than term babies?

IWL

Where does the water go ?

• SENSIBLE loses means - measurable sourcesExamples• Urine• stool (diarrhea and ostomy)• naso/oro gastric drainage• or any other loss .

Where does the water go ?

• INSENSIBLE loses means - UNmeasurable sources

Through…• Skin • Respiratory mucosa

In Sensible Water Loss(IWL)

• Key Variable.• Shared: The skin- 2/3 + Respiratory tract -1/3.• IWL….inversely to…1. Gestational Age (more preterm: more IWL)2. Postnatal age (skin thickens with age: older is better --> less IWL)3. ↑BSA to Wt ratio

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Stratum corneum• The outer most layer of

cells which form theepidermal barrier:

• - 10-20 layers in full term infants

• - 2-3 layers at 30 weeks gestational age

• - Virtually no layers are present at less than

• 24 weeks of gestation

What increases IWL ?

• ↑ RR• Radiant warmer and phototherapy: 50% • High ambient temp: ↑ 30% • Breached skin (removal of adhesive tapes)• Surgical malformations e.g. (gastroschisis, omphalocele,

neural tube defects)• Body temp : ↑ 30% • ↓ Ambient humidity.• ↑ Motor activity, crying: 50-70%

Why to prevent IWL ?

vessel

cell interstitium cell

Na

Na

Na

Na Na

How to reduce IWL

How to reduce IWL ?• non-abrasive tape such as Micropore®.• Use of Tegaderm or Duoderm adhesives.• semipermeable membranes beneatha. neonatal electrodesb. urine bags, c. transcutaneous oxygen electrodes• soft paraffin, or emollient ointments

3

4

2

1

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How to reduce IWL

• Humidification of inspired gases in head box and ventilators

How to reduce IWL ?Use of incubators

Humidification of inspired gases in head box and ventilators

Use of Plexiglas heat shields

Prevent skin injury

Thin transparent plastic barriers

Applying oil / ointment

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So how much water to put back?

Replacement of loss

a. In Sensible Water Lossb. Sensible water loss

GROWTH

endogeous water produced

Blood transfusionsIV Pushes

Fluid requirements……VOLUME….

Day 1 Day 2-3 Day 4-5 Day 6-7

< 1 kg 80-100 120 140 150

1-1.5 kg 80 100 120 150

>1.5 kg 60 80 110 150

↑15-20 ml/kg/day

↑15-20 ml/kg/day

↑15-20 ml/kg/day

Why do all the newborns – preterm or full term require same

amount at 1 week age…?

B’cause – stratum corneum matures

Basic Principles for Fluid Prescription

• The birth weight to be taken in consideration till baby grows beyond.

• Add extra for the conditions which increase IN-SENSIBLE or SENSIBLE loses. eg. 20ml/kg for photo therapy or radiant warmer.• Final total volume calculated for 24 hrs.• Revise prescription every 4-6 hrly.

Restricted versus liberal water intake

“ restriction of water intake so that physiological needs are met without allowing significant dehydration is expected to decrease the risks of PDA and NEC without significantly increasing the risk of adverse consequences.”

- Bell EF, Acarregui MJ - The Cochrane Library, Issue 1, 2008

Prescribing Fluid Therapy• Baby … Birth weight ….. Day of Life• Total volume = basic fluid (ml/kg) + Insensible loss of RW/Photo + Sensible loss of Aspirates / Drains

- fluid used used for # for dilution of drugs # I/V Pushes or boluses # Blood products transfusion

• Devide the volume in various sub heads I/V fluids Feed volume

ml @ hour

Actual Volume

Changing EquationsSituation Recommendation

Watery diarrhoea Maintainance + on going loses

(5ml/kg/freq )Intestinal obstructions Maintainance + Aspirates + Drains

NEC 180 ml/kg

P.D.A. 100-120 ml/kg

Acute Renal Failure(established/ Renal)

400 ml/ m2 or 40ml / kg

C.L.D. 120 ml/kg

Accuracy in prescription

• Write neatly.• Use calculators.• Show all steps of counting.• Double check.• Fluid rate always in ml/ hr… NOT mg/kg/min• Fluid orders to be designed for small intervals.• Keep reviewing.

Calculators for your desktop

I am not fond of calculation…!

But I am tech savy…!

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Accuracy in Fluid Delivery• Use of Infusion Pump for I/V

Maintenance.• Use of Syringe Pump for Drug

infusions.• Proper Input and Out put

Nursing Chart.• If no gazets…use Pediatric Drip

sets. (ml @ hour = micro drops /min)

Monitoring the Fluid therapy

• Daily weight• Urine out put• Other drains out put.(eg.NG)• Vitals – blood pressure – signs of DehydrationLabs: 1. urine specific gravity / osmolality/ Na+

2. Serum Na+

3. FEN(fractional excretion of sodium)

Electrolytes Prescription

• Day 1 - 2: 10% dextrose

• Day 3 onwards : + Electrolytes Na….3mq/kg/day K ……2mq/kg/day (ensure adequate U/O)

• Ped. Maintenance: 5-10%D+ 1/6 N saline

Parenteral Fluids

Solution Glucose (g/L) Na+ K+ Cl- Lactate mOsm/l

10% Dextrose 100 0 0 0 0 500

5% Dextrose (D5W) 50 0 0 0 0 250

0.9% Normal Saline (NS) 0 154 0 154 0 308

D5 0.9NS 50 154 0 154 0 560

D5½NS ( 0.45%) 50 77 0 77 0 406

D5¼NS(0.2%) 50 38 38 0 320

Isolyte-P 50 25 20 22 0 368

Hyper NatremiaDue to Excessive water loss• Insensible loss

in Summers due to inadequate feeding under radiant warmer Open body defects

• Sensible loss in extreme prematures diarrhoea

Hyper Natremia

Due to excess of Sodium

Breast Milk hypernatremia Iatrogenic – Soda bicarbonate use. In drug formulas Improper dispension (eg ORS).

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Hyponatremia

• Diuretics• glycosuria • renal water and sodium

wasting (VLBW)• adrenal and renal tubular

disorders• GI Losses and third

spacelosses of ECF ( skin sloughing, early NEC)

• Inappropriate Secretion of Antidiuretic Hormone

(SIADH)

Treating acute phase :<125 mEq /L or Symptomatic1 ml/kg of 3% NaCl (0.5 meq/mlDose… 4ml/kg over 2-3 min

Hyper Kalemia [K+] >6 mEq/L)• Non oliguric hyperkalemia (ELBW)• Acute Renal Failure• Acidosis• Cong.Adrenal Hyperplasia• Intra ventricular Hemorrhage• blood transfusion (>7 days stored)

Newborns are usually resistant to cardiac arrythmia from Hyper kalemia.

Incr

easin

g Se

rum

K+

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Treatment for Hyper kalemiaMembrane Stabilization (↓ membrane excitability) IV calcium 1-2 cc/kg

(10%)

Internal Redistribution IV insulin glucose drip IV NaHCO3 1-2 mEq/kg IV -adrenergic agonist

(salbutomol inhalation)

Enhanced Elimination

Kayexalate

Loop diuretic..Lasix

Peritoneal dialysis

Exchange Transfusion

a maulik shah presentation

Friends, Let’s Share our views….DR.MAULIK SHAH MD.(PED)

ASSOCIATE PROFESSOR OF PEDIATRICSM.P.SHAH MEDICAL COLLEGE,

JAMNAGAR.maulikdr@gmail.com

Visit : http://matrutvanikediae.blogspot.com