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WHY THIS BORING TOPIC. q Intake of Sick Newborn – at the mercy of neonatologist. q Small amount of fluid can make a big difference. q Fluid Overload - may lead to NEC, PDA, CLD. HOW WET ARE THE NEWBORN. q TBW - 0.7 L/kg in Newborn 0.6 L/kg at 1yr. Age q ECF 40% - Newborn

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WHY THIS BORING TOPIC

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Why this boring topic l.jpg

WHY THIS BORING TOPIC

q Intake of Sick Newborn – at the mercy of neonatologist.

q Small amount of fluid can make a big difference.

q Fluid Overload - may lead to NEC, PDA, CLD.


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HOW WET ARE THE NEWBORN

q TBW -0.7 L/kg in Newborn

0.6 L/kg at 1yr. Age

q ECF40% - Newborn

20% - Older Children


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WHO REQUIRE FLUID

qInfant < 30 wks. & <1250 gm.

qSick Term Newborns

- Severe birth asphyxia

- Apnoea

- RDS

- Sepsis

- Seizure


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HOW MUCH FLUID TO BE GIVEN

<1 kg1-1.5 kg.>1.5 kg.

1st day 100 ml/kg.80 ml/kg. 60 ml/kg.

7th day 190/ml/kg170 ml/kg 150 ml/kg.

q increase 15 ml/kg/day upto 6th day

q Add  20 ml/kg/day for Phototherapy & Warmer.

qAll calculation done on birth wt. till body wt. exceeds birth wt.

q Fluid if prematures nursed in Plastic heat Sheild


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WHAT FLUID

1st 48 hrs.<1 kg- 5% Dextrose

1-1.5 kg.- 10% Dextrose

>1.5 kg.- 10% Dextrose

After that ISO – P Na+ - 20 mEq / lit

K+ - 20 mEq / lit

Cl - 25 mEq / lit

D - 5%

25ml 25% D+ 75ml

ISO – P Na+ - 22.7 mEq / lit

K+ - 18 mEq / lit

Cl - 22 mEq / lit

D - 10%


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LESS FLUID

Birth asphyxia

Meningitis

Pneumothorax

IVH

PDA

CLD

2/3 of Maintenance


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EXTRA FLUID

q NEC & other condition with loss in 3rd space

  • May require upto 200ml / kg – repeated 10ml / kg RL/NS bolus.

    q ELBW / VLBW neonates – Due to high IWL.


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KEY POINTS TO REMEMBER IN FLUID THERAPY

Term – 1% Per day

qAllow a wt. Loss

Preterm – 2% Per day

q 1st 48 hrs – no electrolyte required

q Replace  Gastric fluid loss  ½ NS + KCL

 Other body fluids  NS + KCL

q Give fluid direction 8-12 hrly in sick neonates


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Premature 1.25 kg. day 1 give fluid direction

q 10% Dextrose

q 80 ml / day

q 20 ml 6 hourly

q 10% Dextrose 3.5ml / hr = 3 drops / min


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A 3 kgs., term sick newborn on 4th day under radiant

warmer & phototherapy, calculate fluid requirement

q ISO – P

q 315 ml + 60 ml + 60 ml = 435 ml

q 108 ml / 6 hrs.

q 18 ml / hr. = 18 drops / min.


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ELECTROLYTE REQUIREMENT

  • SODIUM :

  • Add -from day 2 - 3

  • In VLBW add when lost 6% wt.

  • Require -Term & LBW  2 - 3 mEq / kg / day

  • ELBW  3 - 5 mEq / kg / day


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ELECTROLYTE REQUIREMENT….

  • POTASIUM :

  • Add -from day 3

  • can wait till serum K+ < 4 in small

  • prematures

  • Require -2 - 3 mEq / kg / day


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ELECTROLYTE REQUIREMENT....

C.CALCIUM :q Give to IDM

Preterm

Birth asphyxia

<1500 gm.

q Add from day 1.

q 36-72 mEq / kg / day

or

4- 8 ml / kg / day of 10% Cal. gluconate


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GLUCOSE REQUIREMENT

qOptimum requirement 4-6 mg / kg / min

q Conc. Used - 5%, 10%, 12.5% (max)

q Glucose infuse – (mg / kg / min) = % Gx rate (ml / hr.)

x 0.167 x wt.

q Thumb rule – 3 ml / kg / hr of 10% D = 5mg / kg / min

q Remain careful about glucose in – LBW

IDM

IUGR


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GOALS OF FLUID ELECTROLYTE THERAPY

q Urine output 1 – 3 ml/kg/hr.

q Allow a weight loss 1 – 2% / day in 1st wk.

(weigh the splint before putting i/v line)

q Absence of Edema / Dehydration / Hepatomegaly

q Urine Sp. gravity 1005 - 1015

q Euglycaemia - 75 – 100 mg / dl

q Normonatremia -135 - 145 mEq / lit

q Normokalemia - 4 – 5 mEq / lit


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MONITORING FLUID ELECTROLYTE THERAPY

Check Daily - Definitely

q Wt. - loss > 3% - dehydration

<1% over dehydration

q Urine output <1 ml / kg / hr – dehydration or SIADH

(Hourly) >4 ml / kg / hr. – overhydration / dieresis

Napkin weight technique

Collect in syringe from cotton

q Urine specific gravity >1015 fluid deficit

(each sample if possible) <1005 fluid overload

q Blood Glucose

q Clinical Signs


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MONITORING FLUID ELECTROLYTE THERAPY …...

Check Daily --- if possible

q Serum Na+

q Serum K+

q Blood Urea

q Serum Creatinine


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Peripheral lines: Indications & Purpose

  • Maintain fluid, electrolyte & acid-base balance in neonate

  • Provide IV medications.

  • Provide blood or blood components.

  • Provide peripheral parenteral nutrition.

  • N B: do not try > 2consecutive times by the same person !


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Preliminary steps


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Insertion of Line


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Monitoring & Discontinuation

  • Observe rate, patency ,air within the line.

  • Observe for local warmth, pain,leak redeness ,edema, blanching.

  • Flush with 2 ml N.Saline (with asepsis) if needed to check the line.

  • Indication : on order / leak / phlebitis / thrombosis / blanching (except with ionotrope infusion).

  • Stop fluid / asepsis / remove dressings / remove cannula / press until bleeding stops / dress with iodine.

  • Send cannula tip for culture if phlebitis.


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Umbilical venous line

  • Purpose : Central line for medication, exchange transfusion, pressure monitoring and fluid (rarely)

  • Policy : Should be done by a doctor only.

  • Emphasis : Tip in ductus/IVC, do not advance once secured, do not keep open, very careful about sepsis.

  • Equipment : 5Fr for < 3.5 kg; 8Fr for > 3.5kg.( It should have side holes at tip ), forceps, scalpel,probe, suture, drapes, asepsis utensils, tapes, ties etc. )


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UVC Procedure

  • Estimate length of the catheter(graph), assemble equipments

  • Universal asepsis.

  • Identify UV( patulous, single, bleeding, at 12 o’clock) / grasp cord with toothed forceps / remove clots from vein by iris forcep

  • Introduce fluid filled catheter with stop cock 2-3 cm inside vein / suck for blood / remove clot if no free flow of blood /remove, rotate & reinsert until free flow comes / advance to desired length

  • Fix UVC once free flow established with tapes. Radiology confirmation (D9-D10 or just above right diaphragm).


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Capillary Blood Sampling

  • Purpose : heel prick blood sampling

  • Emphasis : safe and effective / maxm. 2 pricks per heel (except sick newborn).

  • Policy : preferably doctors/ only trained nurse.

  • Indications : sugar / blood gas / Hct / sepsis screen / bilirubin / biochemistry.

  • Equipment: asepsis utensils, lancet, capillary tubes, gauze.


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Procedure of CBS

  • Ask sister to bundle the neonate. Chose the site (picture). Warm the area with dry warm cloth.

  • Universal asepsis. Perform lancet puncture in most medial or lateral aspect of plantar surface (avoid puncture on previous or previous weight bearing sites of the neonates).

  • Discard first drop of blood / hold the site downward / keep gentle continuous pressure /avoid ‘milking’ / Collect in capillary tube /

  • Stop bleeding by pressure / apply Iodine / label each tube / send with details quickly / document all details.


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Special situations


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CASE

  • 1250 gm. 26 wk. Premature, intubated & Ventilated

  •  dev. apnoea on day 5 started i/v aminophylline

  •  day 15 Switched to oral theophylline

  •  day 20 on EBM 150 ml/kg

  •  day 28  Na+ 133 mEq / lit, K+ 4mEq / lit urine output 2-4 ml / kg / hr

  • Day 30  Na+ <100 mEq / lit , serum osmola 204 mosm / lit

    Urine Sp gr. 1040.

  •  From 28 –30th day gained wt. 25 gm / day despite a fall of

  • Urine vol from 3 ml / kg / hr. 0.5 ml / kg / hr

  • qDiagnosis

  • q Management


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CASE….

- A 30 yrs Woman P2+o taken to labour room

- In last 1 hr of labour woman drunk 3L water + received

5% D i/v

- Delivered male baby 3kg, apgar 18 59

- after 6 hrs. the baby dev. Seizure

q What is the most likely cause of seizure?

q How to prevent this?


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HYPONATREMIA

qSerum Na+ <130 mEq / lit

q Neurological Signs or Na+ <120 mEq / lit

 treat promptly

qWhat to give :

3% Nacl  0.5 mEq Na+ / ml

 2 – 3 ml /kg initial dose

 use 3% Nacl to raise Na+ upto 125 mEq / lit

q NaHco3 7.5% solution  0.9 mEq Na+ / ml

(if 3% Nacl not available)


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HYPONATREMIA…….

qHow to calculate deficit

 Na+ deficit (mEq) = (desired Na+ - obs Na+) x wt x 0.6

 Add next 2 days daily requirement 2-3 mEq / kg / day

 correct in 48 hrs.

q Thumb rule - correct1/3rd 8hr

1/3rd 16 hr

1/3rd 24 - 48 hr.


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Male baby of 7 days wt. 1.5 kgs., serum Na+ obs. 122 mEq. / lt.

How to correct the hyponatremia ?

q Deficit of Na+ = (135 – 122) x 1.5 x 0.6 = 11.7 mEq.

q Maintenance Na+ = 3 x 1.5 x 2 (correction made in 48 hrs.)

= 9 mEq.

q Total requirements = 11.7 +9 = 20.7 mEq. = 21 mEq.

q Fluid requirements for 48 hrs. = 1.5 x 150 x 2 = 450 ml.

q 21 mEq Na+ in 450 ml. fluid = 50 mEq. Na+ in 1 lit.

q Fluid required = 450 ml. N/3 Solution.


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HYPERNATREMIA

q Serum Na> 150 mEq / lit

q Excess free water loss than Na+

q Do not treat with Na+ free water

q Fluid therapy -- 2/3 maintenance with N2 / N5 sol. + 5% D.

-- correct Na+ over 24 – 48 hrs. Do not drop >10 mEq / lit / day.

-- May require 3% NaCl if over correctionleads to CNS signs.


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SIADH

q Predisposing factors present

Feature q wt. Gain with out oedema

q hypotonic hyponatremia

q Urine output

q Urine osmolality > plasma osmolality

Treat q Water restriction – 2/3 maintenance x 24 hrs

q 3% Nacl if Na+ <120 mEq / lit or CNS sign

q Frusemide  Urinary electrolyte free H2o excretion


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HYPOKALEMIA

A Newborn 3kgs on 2nd day developed abdominal distension, NG tube inserted, on 3rd day Serum K+ observed was 2.1 mEq / lit. How to correct.

K+ deficit = (Req K+ - obs K+) x body wt.

3

= (3.5 - 2.1) x 3

3

= 1.4 mEq


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HYPOKALEMIA ………

q Max K+ i/v without ECG - monitoring – 40 mEq / lit = 2ml 1.5ml KCL / 100ml of Fluid.

q Max K+ i/v with ECG – monitoring – 60 - 80 mEq / lit

q Signs of hypokalenia in newborn – ileus

Obtundation

 QT / ST depression


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HYPERKALEMIA

q Serum K+ > 6 mEq / lit

q How to manage

1. Check Sampling error and Recheck Value

2. Remove all sources of K+

3. Upto 7mEq / lit  Kayexelate 1gm / kg at 0.5gm / ml of NS given as enema (upto 1- 3 cm)  minimum retention time = 30 min.


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  • HYPERKALEMIA….

  • K+ > 7 mEq / lit - Co – gluconate 1- 2ml / kg over 5 min

  • - NaHCo31 – 2ml / kg slowly

  • - 2ml / kg of 10% D + 0.05 units / kg regular insulin followed by – infusion

  • - Kayexelate

  • - Salbatatnoe Nebalisation 4mcg / kg

  • 5.If above measure fails 

  • Peritoneal dialysis

  •  Exchange transfusion

  • ECG  Tall  T /  PR /  QRS


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Commercial electrolyte and dextrose stock sol.


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Composition of commercial I.V. fluid available


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HYPOCALCAEMIA

Serum Calcium <7.0 mg / dl Ionised Cal <4.0 mg / dl

Seizure

Treatment of Hypocalcaemic Crisis apnoea

Tetaxy

1 – 2ml Ca-glu. / kg + 5 - 10% D 10ml over 10 min.

No response in 10min  REPEAT DOSE

Maintenance Cal  8ml / kg / day x 48 hrs.

Switch to oral therapy


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HYPOCALCAEMIA ………

Refactory hypocalcaemia  think hypomagnesaemia  0.2ml of 50% mgso4 2 doses 12hr. Apart i/v or deep im

Caution in Ca++ therapy

q Rapid i/v infusion - dysrythmia / bradycardia

q Extravasation of Ca++ Solution  S/C necrosis & Calcification


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Thank U


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