Fluid - electrolytes management in Newborns

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.

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vessel cell interstitium cell INTRA CELLULAR fluid EXTRA CELLULAR fluid

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vessel cell interstitium EXTRA CELLULAR fluid INTRA CELLULAR fluid

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0 3 6 9 // 0 3 6 9 0 20 40 60 80 100 Age in months Fetus N e w- B o r n B 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 : 

Changes during delivery & labour vessel cell interstitium cell

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

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

Why Preterm babies loose more wt than term babies? : 

Why Preterm babies loose more wt than term babies? IWL

Where does the water go ? : 

Where does the water go ? SENSIBLE loses means - measurable sources Examples Urine stool (diarrhea and ostomy) naso/oro gastric drainage or any other loss .

Where does the water go ? : 

Where does the water go ? INSENSIBLE loses means - UNmeasurable sources Through… Skin Respiratory mucosa

In Sensible Water Loss(IWL) : 

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

Stratum corneum : 

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 ? : 

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 ? : 

Why to prevent IWL ? vessel cell interstitium cell Na Na Na Na Na

How to reduce IWL : 

How to reduce IWL

How to reduce IWL ? : 

How to reduce IWL ? non-abrasive tape such as Micropore®. Use of Tegaderm or Duoderm adhesives. semipermeable membranes beneath neonatal electrodes urine bags, transcutaneous oxygen electrodes soft paraffin, or emollient ointments 3 4 2 1

Adhesives & Skin : 

Adhesives & Skin Adhesive removal is the primary cause of skin breakdown. Recommended Practices Applying Adhesive Minimize amount of adhesive in contact with skin Use smaller pieces of tape Use “double-backed” tape Deactivate adhesive with cotton balls when full adhesion not required Do not use bonding agents (benzoin) to enhance adhesion Avoid bandages after heel sticks. Use pressure with a cotton ball or gauze  Removing Adhesive Loosen adhesive with mineral oil or petrolatum-based emollients Slowly fold adhesive back onto itself while moistening the adhesive-skin surface with water-soaked cotton balls Avoid solvents due to potential and proven toxicity

How to reduce IWL : 

How to reduce IWL Humidification of inspired gases in head box and ventilators

How to reduce IWL ? : 

How to reduce IWL ?

How to calculate IWL ? : 

How to calculate IWL ? IWL = Fluid intake - Urine output + weight loss (or – weight gain) Eg. 3 kg baby onD-2 : 60ml/kg + 20ml/kg for RW = 240 ml intake - 50 ml urine out put -30 gm wt. gain so total : 160 /3 = 53 ml / kg IWL

How to utilize IWL measures? : 

How to utilize IWL measures? Eg. 3 kg baby on day 2 : 200 ml intake 53 ml / kg IWL Intake was planned - 60ml /kg As a routine next would be – 75ml/kg But baby is retaining fluid – so ideal would be… 53ml/kg

So how much water to put back? : 

So how much water to put back? Replacement of loss In Sensible Water Loss Sensible water loss GROWTH endogeous water produced Blood transfusions IV Pushes

The Fluid Equation : 

The Fluid Equation

Fluid requirements……VOLUME…. : 

Fluid requirements……VOLUME…. ↑ 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…? : 

Why do all the newborns – preterm or full term require same amount at 1 week age…?

B’cause – stratum corneum matures : 

B’cause – stratum corneum matures

Basic Principles for Fluid Prescription : 

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 : 

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 : 

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 Equations : 

Changing Equations

Accuracy in prescription : 

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.

I am not fond of calculation…! : 

Calculators for your desktop I am not fond of calculation…! But I am tech savy…!

Accuracy in Fluid Delivery : 

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 : 

Monitoring the Fluid therapy Daily weight Urine out put Other drains out put.(eg.NG) Vitals – blood pressure – signs of Dehydration Labs: urine specific gravity / osmolality/ Na+ Serum Na+ FEN(fractional excretion of sodium)

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Day 18 –Baby wt 1250gm today weight 1.3kg Under radiant warmer NG Aspirates = 5cc last 24hrs On half ivfluid and NG tube feeding 40cc/kg Planned for a PCV transfusion 20 cc today. Prescribe fluid & feed plan. 22 Total volume = IVF + 52/12=4ML/2HR FEED 205-52=153ML/24= 6ML/HR IVF

Electrolytes Prescription : 

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 : 

Parenteral Fluids

Hyper Natremia : 

Hyper Natremia Due 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 : 

Hyper Natremia Due to excess of Sodium Breast Milk hypernatremia Iatrogenic – Soda bicarbonate use. In drug formulas Improper dispension (eg ORS).

Hyponatremia : 

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 Symptomatic 1 ml/kg of 3% NaCl (0.5 meq/ml Dose… 4ml/kg over 2-3 min

Hyper Kalemia [K+] >6 mEq/L) : 

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.

Treatment for Hyper kalemia : 

Treatment for Hyper kalemia Membrane 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

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Friends, Let’s Share our views…. DR.MAULIK SHAH MD.(PED) ASSOCIATE PROFESSOR OF PEDIATRICS M.P.SHAH MEDICAL COLLEGE, JAMNAGAR. maulikdr@gmail.com Visit : http://matrutvanikediae.blogspot.com a maulik shah presentation