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WORKSHOP onNEONATAL FLUID ELECTROLYTE THERAPYPresented By : Dr. Swapan Chakraborty Dr. Subhasis Roy Dr. Subrata Chakraborty Dr. Amit Roy Dr. A. Moulik Dr. Atul Gupta

WHY THIS BORING TOPIC

skin

Intake = output renal

fecal

sound knowledge 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 ECF40% - Newborn

20% - Older Children

WHO REQUIRE FLUID

qInfant < 30 wks. & <1250 gm.

qSick Term Newborns

- Severe birth asphyxia

- Apnoea

- RDS

- Sepsis

- Seizure

HOW MUCH FLUID TO BE GIVEN

<1 kg 1-1.5 kg. >1.5 kg.

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

7th day 190/ml/kg 170 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

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%

OR 25ml 25% D+ 75ml

ISO – P Na+ - 22.7 mEq / lit

K+ - 18 mEq / lit

Cl - 22 mEq / lit

cv D - 10%

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.

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

Premature 1.25 kg. day 1 give fluid direction

q 10% Dextrose

q 100 ml / day

q 25 ml 6 hourly

q 10% Dextrose 4 ml / hr = 4drops / min

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.

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

ELECTROLYTE REQUIREMENT….

- POTASIUM :
- Add - from day 3
- can wait till serum K+ < 4 in small
- prematures
- Require - 2 - 3 mEq / kg / day

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

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

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

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

MONITORING FLUID ELECTROLYTE THERAPY …...

Check Daily - if possible

q Serum Na+

q Serum K+

q Blood Urea

q Serum Creatinine

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

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?

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)

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 - correct 1/3rd 8hr

1/3rd 16 hr

1/3rd 24 - 48 hr.

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.

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 correction leads to CNS signs.

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

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

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

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

qSigns of hypokalenia in newborn – ileus

Obtundation

QT / ST depression

HYPERKALEMIA

q Serum K+ > 6 mEq / lit

qHow 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.

- K+ > 7 mEq / lit - Ca – gluconate 1- 2ml / kg over 5 min
- - NaHCo3 1 – 2ml / kg slowly
- - 2ml / kg of 10% D + 0.05 units / kg regular insulin followed by – infusion
- - Kayexelate
- - Salbutamol Nebulisation 4mcg / kg
- 5. If above measure fails
- Peritoneal dialysis
- Exchange transfusion
- ECG Tall - T / PR / QRS

HYPOCALCAEMIA

Serum calcium <7.0 mg / dl ionised cal <4.0 mg / dl

Seizure

Treatment of Hypocalcaemic Crisis apnoea

Tetany

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

Refractory 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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