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,
Visit : http://matrutvanikediae.blogspot.com