Management of Fluid and Electrolytes in Newborn :Management of Fluid and Electrolytes in Newborn Dr Vishram Buche Director, NICU Central InDIA’S CHILD hOSPITAL & Research INSTITUTE NAGPUR INDIA


Slide 2:Central India’s C H I L D HOSPITAL & Research Institute


Slide 3:ADVANCED NEONATAL CARE CENTRE


Physiological facts……..1 :Physiological facts……..1 And …….Renal Function


Slide 6:0 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


Slide 7:Why Newborn / preterm babies have large amount of water than older infants ? Why Preterm babies loose more wt than term babies?


Potassium…..Non-oliguric Hyperkalemia…. :Potassium…..Non-oliguric Hyperkalemia….


Clinical significance: :Clinical significance:


Fluid losses…. :Fluid losses….


Slide 12:3 Days old ….1kg… Preterm , ≤ 32 wks !!! …….Which would be more IWL OR Urine output ?...... Just try to calculate…………!!!


Increased insensible water loss (IWL) :Increased insensible water loss (IWL)


Decreased insensible water loss (IWL)… ……………Or Measures to ↓ IWL :Decreased insensible water loss (IWL)… ……………Or Measures to ↓ IWL      


Clinical Implications….. :Clinical Implications….. Failure to prevent….


Physiological facts….2 RENAL Prematurity :Limited capacity to concentrate or dilute urine, neither excrete and conserve Na. Esp.. Preterm babies limited tubular capacity to reabsorb Na. Limited capacity to acidify urine GFR  gestational age Physiological facts….2 RENAL Prematurity


Slide 17:Adult Term Preterm Concen. capacity Diluting capacity 1500 800 600 50 mOsmol/kg Renal Prematurity cont… Limited capacity….. CONCENTRATE and dilute urine


Clinical implications…. :Clinical implications…. Risk to develop….. Hypernitremia (Dehydration) Hyponitremia (Over-hydration) Hyperkalemia Acidosis Failure to concentrate and dilute…..


Word of Caution……. :Word of Caution……. Babies < 30-32 wks gestn may continue to pass large amounts of dilute urine despite dehydration becoz of renal immaturity. Hence urine output and specific gravity maybe an unreliable indicator of fluid status in these babies.


Slide 20:Suggested Protocol…


F/E phases in early neonatal Period…… :F/E phases in early neonatal Period……


Fluid requirements……Volume…. :Fluid requirements……Volume….


…. :…. Starting Volume… 60-80-100 ml/kg/day Increase ………15-20 ml/kg/day… max 150-160 ml by 6-7th day. 20 ml /kg /day


Thumb rules…. :Thumb rules…. Start….1st day……2.5-3.5 ml / kg / hr Add….0.5 ml to 1ml / kg /day Wkend…..5-6 ml / kg / hr Higher wt, Term …..lower requirement Lower wt, Preterm ….. Higher requirement


Slide 26:Lytes…….


Slide 27:Electrolytes 0 0.5 0.75 1.0 1.5 1.75 2 .0 2.5 3 Wt in Kg 8 7 6 5 4 3 2 1 Glucose GM% mEq / 100 ml K+


Type…. :Type…. Day 1 - 2: 10% dextrose Day 3 onwards : + Electrolytes Na….3mq/kg/day K ……2mq/kg/day (ensure adequate U/O) (10%D+1/6 N saline) Ped maintenance solution + 50% D to make up 10% concentration (10:1 proportion) (Na 22.7mEq/L, K 18mEq/L) <32 weeks – More Na.


Slide 29:Why Preterm/LBW require more Na than full-term babies ? Why no ‘lytes in 1st 48 hrs of newborn life ? Why glucose requirement is higher in Preterm / LBW babies?


Slide 30:Baby weight 1.2 kg , fluid requirement ? would it be same ? Ask yourself ? What is the gestational age ?


Guidelines for Initiating and Adjusting Fluid and Electrolyte Therapy in Newborns :Guidelines for Initiating and Adjusting Fluid and Electrolyte Therapy in Newborns Lorenz JM. Fluid and electrolyte therapy in the newborn infant. In: Burg FD, Polin RA, Ingelfinger JR, Gershon A, eds.Current Pediatric Therapy 17. Philadelphia, Pa: WB Saunders; 2002.


Slide 32:How these figures of volumes are calculated? Why preterm / LBW require more fluids than full-term babies? Fluid required = IWL + UOP + Growth req + stool loss – endogeous water produced – postnatal loss


To keep in mind…………… :To keep in mind……………


Slide 35:Specific situations…..


Special situations…. :Special situations…. NO COOK-BOOK APPROACH


Monitoring Fluid therapy of the neonates :Monitoring Fluid therapy of the neonates


Slide 38: ↑ Osmolality + ↑ Na ↓ Osmolality + ↓ Na


Of limited value…….. :Of limited value……..


Goals of fluid therapy…. :Goals of fluid therapy…. Urine output 1-3 ml/kg/hour Urine specific gravity 1005-1015 (urine osmolality 100-400) Daily weight loss 1-3% of body weight Plasma osmolality… 270-285mOsmol/kg Absence of edema or dehydration Maintenance of euglycemia (75-100 mg/dl), Normonatremia (serum Na+ 135-145 meq/l) Normokalemia (serum K+ 4-5 meq/ l)


Based on above principles….. :Based on above principles…..


Electrolytes Problems….. :Electrolytes Problems…..


HyperNa+ …….. :HyperNa+ …….. IWL… More in Preterm


Na interpretation….in clinical context :Na interpretation….in clinical context Is the baby dehydrated ? Are there ongoing losses ? Is UOP ed ? Is the specific gravity  ed ? Any medications vth  con of Na


HypoNa…. :HypoNa…. Prematurity….renal Na Loss from ↑FEN Inadequate Na intake…?hypotonic IV Excessive water intake…mother IV..5%D Diuretics..Lasix ATN (tubular Na loss)….renal Failure SIADH Excess Na loss…Diarrhoea ? Indomethacin


Acute symptomatic HypoNa…. :Acute symptomatic HypoNa…. 1 ml/kg of 3% NaCl (0.5 meq/ml)….. …. ↑ Na 1.5 mEq/l Dose… 4ml/kg over 2-3 min Or NAHCO3 …… 1ml/kg…..↑Na ..3mEq/l 2 ml/kg over 2-3 min


HyperK+alemia…… :HyperK+alemia…… K


HyperK+alemia…… :Def & ∆… K > 6 (unhaemolysed sample) pH affects K+ …… 0.1 pH change…0.3-0.6 K+ change (▲acid…more K; ▼ acid…less K) Aetiology…… Oliguric Renal failure, Non-oliguric hyperK….▲by dehydrn. Sick cell syndrome 20 Hypoxia CAH, IVH HyperK+alemia…… In general K++ ….well tolerated by neonates K


Treatment…… :Treatment…… Membrane Stabilization (↓ membrane excitability) IV calcium 1-2 cc/kg (10%) Internal Redistribution IV insulin (+ glucose) IV NaHCO3 1-2 mEq/kg IV -adrenergic agonist (salbutomol inhalation) Enhanced Elimination Kayexalate Loop diuretic..Lasix Peritoneal / Hemo…dialysis…Exchange Transfusion


EKG Manifestations of Hyperkalemia :EKG Manifestations of Hyperkalemia Earliest to appear


EKG Manifestations of Hyperkalemia :EKG Manifestations of Hyperkalemia Earliest to appear


EKG Manifestations of Hypokalemia :EKG Manifestations of Hypokalemia


Slide 55:Restrictive strategy of fluids: There has been a lot of interest in the amount of fluid therapy and outcome of preterm neonates in terms of mortality and morbidity. The Cochrane meta-analysis on this topic could identify four eligible studies. Their findings state that, although restricted fluid therapy may lead to greater weight loss and dehydration, it is associated with a decreased incidence of death, PDA and NEC. There also seems to be a beneficial effect of restricted fluid therapy on the incidence of BPD.


Slide 56:The volume of fluids used in the restricted groups differs from the above-described fluid therapy by 20-50 ml/kg/day in the initial 3-4 days. Based on their meta-analysis, the investigators had concluded that fluid therapy needs to be balanced enough to meet the normal physiological needs without allowing significant dehydration. Bell EF, Acarrgui MJ. Restricted versus liberal water intake for preventing morbidity and mortality in preterm infants. Cochrane Database Syst Rev 2000,(2):CD000503


Common Parenteral Fluids……………. :Common Parenteral Fluids……………. Isolyte-P 50 25 20 22 0 368


Key points…….. :Key points…….. Maintenance Fluid 1st day….2.5-3.5ml/kg/hr. Volume 5-6ml/kg/hr by wkend. Electrolytes after 48 hrs. Add K after pee Frequent clinical/ Lab monitoring…essential. “No cook book approach” Consideration of Restrictive strategy.


Slide 59:Rare cases of F/E imbalance to alert Pediatrician……


Slide 60:Preterm…Abnormal Facies 4th G mother , vth bad obstetric, h/o…3 abortions, H/o Polyhydramnios H/o BA…..mild RDS…recovered… Persistantly Dehydrated (s/o volume depleted..↓BP)… Still Polyuric….. difficult to correct Lab: Urine…. Ca +++ Electrolytes ( Na, K, Cl, N..Mg), ABG …….↑pH, ↑HCO3, ↑pCO2 Key LAB report …..1. ↑R. 2.↑A USG… Nephrocalcinosis 1……


Slide 61:A Poor Dehydrated Baby…. Triangular Face Prominent Forehead Large eyes Strabismus Protruding ears


Slide 62:Preterm… PolyHydramnios …polyuric Hyponitremia HypoKalemic Hypochloremic Metabolic Alkalosis ↑R ↑A Autosomal recessive Antenatal Diagnosis possible ……K wasting Disorder……. BARTTER SYNDROME enin ldosteron


Slide 63:8days old …..Full Term baby….3.5kg…. Severely Dehydrated ( 17% wt loss since birth) Didn’t respond to IV fluid Refractory to supportive t/t No evidence of UTI, Obstructive uropathy Lab…. ↓Na , ↑K ↓ pH, ↓HCO3, ↓pCO2 EVEN to A DOSE OF STEROIDES ↑ Sr Cortisol ↓17OH prog ↑ Sr Renin ↑ Sr Aldosteron 2……


Slide 64:Severe Dehy + Meta Acidosis + Hyponitremia+ HyperKalemia Response to steroids Yes NO


In Conclusion…….. :In Conclusion…….. …………………………….. …………………….. ……………………….


Slide 66:THANKS…