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Fluids and Electrolyte Management in Neonates

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Many babies in NICU ... All babies are born with an excess of TBW, mainly ECF, which needs ... excessive hypertonic fluids (sod bicarb in babies with PPHN) ... – PowerPoint PPT presentation

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Title: Fluids and Electrolyte Management in Neonates


1
Fluids and Electrolyte Management in Neonates
  • Arun Manglik, MD, DNB Shishu Sanjivan Hospital
    for Children, Kolkata

2
FE Management in NB
  • Essentials of life
  • Food (Nutrition)
  • Water (Fluid/electrolyte)
  • Shelter (environment control - temperature etc)
  • Essentials of neonatal care
  • Fluid, electrolyte, nutrition management (All
    babies)
  • Control of environment (All babies)
  • Respiratory /CVS/CNS management (some babies)
  • Infection management (some babies)

3
Why is FE management important?
  • Many babies in NICU need IV fluids
  • They all dont need the same IV fluids (either in
    quantity or composition)
  • If wrong fluids are given, NB kidneys are not
    well equipped to handle them
  • Serious morbidity can result from fluid and
    electrolyte imbalance

4
Fluids and Electrolytes
  • Priniciples
  • Total body water (TBW) Intracellular fluid
    (ICF) Extracellular fluid (ECF)
  • Extracellular fluid (ECF) Intravascular fluid
    (in vessels plasma, lymph - IVF) Interstitial
    fluid (between cells - IF)
  • Goals
  • Maintain appropriate ECF volume,
  • Maintain appropriate ECF and ICF osmolality and
    ionic concentrations

5
Things to consider Normal changes in TBW, ECF
  • All babies are born with an excess of TBW, mainly
    ECF, which needs to be removed
  • Adults are 60 water (20 ECF, 40 ICF)
  • Term neonates are 75 water (40 ECF, 35 ICF)
    lose 5-10 of weight in first week
  • Preterm neonates have more water (24 wks 85,
    60 ECF, 25 ICF) lose 5-15 of weight in first
    week

6
Things to consider Normal changes in Renal
Function
  • Neonates are not able to concentrate or dilute
    urine as well as adults - at risk for dehydration
    or fluid overload
  • Solute conc in urine ranges 50-800 mOsm/L in
    terms, 50-600 in PT
  • Renal function matures with increasing
  • gestational age postnatal age

7
Things to consider Insensible water loss (IWL)
  • IWL ? not obvious Skin (2/3) or Resp tract
    (1/3). Depends on
  • gestational age (more PT more IWL)
  • postnatal age (skin thickens with age)
  • also consider losses of other fluids Stool
    (diarrhea/ostomy), NG/OG drainage, CSF
    (ventricular drainage).
  • SWL ? that seen urinestool

8
Insensible water loss (IWL)
9
Factors raising IWL
So more fluids required
  • Raised RR
  • High body/ambient temp 30/C
  • Warmers/PT ? incr IWL 50
  • Incr activity/crying
  • Skin loss, trauma, omphalocele, neural tube
    defects

10
Factors reducing IWL
  • Incubators / humidified inspired gases
  • Plexiglass heat shield
  • Transparent plastic barriers do not interfere
    in warmer functions ? reduce water loss 30

11
Assessment of FE status
  • History babys FE status partially reflects
    moms FE status (Excessive use of oxytocin,
    hypotonic IV fluid ? hyponatremia)
  • Physical Examination
  • Weight reflects TBW but not intravascular volume
    (eg. Long term paralysis and peritonitis ? incr
    BW and incr IF but decreased intravascular
    volume.
  • Moral a puffy baby may or may not have adequate
    fluid where it counts ? in his blood vessels)

12
Weight loss
  • Term ? 1-2/D total 10 loss
  • PT ? 2-3/D total 15 loss
  • This is due to loss of ECW and needs no
    replacement

13
Assessment of FE statusPhysical examination
(Contd)
  • Skin/Mucosa Altered skin turgor, sunken AF, dry
    mucosa, edema etc are not sensitive indicators in
    babies
  • Cardiovascular
  • Tachycardia ? too much (ECF excess in CHF) or too
    little ECF (hypovolemia)
  • Delayed capillary refill ? low cardiac output
  • Hepatomegaly can occur with ECF excess
  • BP changes very late
  • Urine output

14
Assessment of FE status Lab evaluation
  • Serum electrolytes and plasma osmolarity
  • Urine electrolytes, specific gravity (not very
    useful if the baby is on diuretics - lasix etc),
    FENa
  • Blood urea, serum creatinine (values in the first
    few days reflect moms values, not babys)
  • ABG (low pH and bicarb may indicate poor
    perfusion)

15
Management of FE
  • Goal Allow initial loss of ECT over first week
    (as reflected by wt loss), while maintaining
    normal intravascular volume and tonicity (as
    reflected by HR, UOP, lytes, pH). Subsequently,
    maintain water and electrolyte balance, including
    requirements for body growth.
  • Individualize approach (no cook book is good
    enough!)

16
Management of FE - D1 Term
  • Req. Urine IWL Wt loss
  • On IV fluids ? solute load 15mOsm/Kg
  • With urine osmolality 300, urine50ml/Kg
  • IWL 20ml/kg
  • Wt loss 10gm/Kg
  • Req. 50 20 10 60ml/Kg
  • PT ? more IWL

17
Guidelines for FE
18
Let there be lytes!
  • Electrolyte requirements
  • For the first 1-3 days, sodium, potassium, or
    chloride are not generally required
  • Later in the first week, needs are 1-2 mEq/kg/day
    (1 L of NS 150 mEq 150 cc/kg/day of 1/4 NS
    5.9 mEq/kg/day which is too much)
  • After the first week, during growth, needs are
    2-3 or even 4 mEq/kg/day

19
FE in common neonatal conditions
  • RDS Adequate but not too much fluid. Excess
    leads to hyponatremia, risk of BPD. Too little
    leads to hypernatremia, dehydration
  • BPD Need more calories but fluids are usually
    restricted hence the need for rocket fuel. If
    diuretics are used, w/f lyte problems. May need
    extra calcium.
  • PDA Avoid fluid overload. Keep at 120ml/Kg. If
    indocin is used, monitor urine output.

20
FE in common neonatal conditions
  • Asphyxia May have renal injury or SIADH.
    Restrict fluids initially, avoid potassium. May
    need fluid challenge if cause of oliguria is not
    clear.
  • NEC Need more fluids. May go into shock. Give
    200ml/Kg
  • ARFGive 400ml/sq m/D urine output

21
Common lyte problems
  • Sodium
  • Hypo (
  • Hyper (150 mEq/L worry if 150)
  • Potassium
  • Hypo (
  • Hyper 6 mEq/L (non-hemolyzed)
  • (worry if 6.5 or if ECG changes )
  • Calcium
  • Hypo (total
  • Hyper (total11 ion5)

22
Hyponatremia
  • Sodium levels often reflect fluid status rather
    than sodium intake

23
Hypernatremia
  • Hypernatremia is usually due to excessive IWL in
    first few days in VLBW infants (micropremies).
    Increase fluid intake and decrease IWL.
  • Rarely due to excessive hypertonic fluids (sod
    bicarb in babies with PPHN). Decrease sodium
    intake.

24
Potassium stuff
  • Potassium is mostly intracellular blood levels
    do not usually indicate total-body potassium
  • pH affects K 0.1 pH change0.3-0.6 K change
    (More acid, more K less acid, less K)
  • ECG affected by both HypoK and HyperK
  • Hypokflat T, prolonged QT, U waves
  • HyperK peaked T waves, widened QRS, bradycardia,
    tachycardia, SVT, V tach, V fib

25
Hypo- and Hyper-K
  • Hypokalemia
  • Leads to arrhythmias, ileus, lethargy
  • Due to chronic diuretic use, NG drainage
  • Treat by giving more potassium slowly
  • Hyperkalemia
  • Increased K release from cells following IVH,
    asphyxia, trauma, IV hemolysis
  • Decreased K excretion with renal failure, CAH
  • Medication error very common

26
Management of Hyperkalemia
  • Stop all fluids with potassium
  • Calcium gluconate 1-2 cc/kg (10) IV
  • Sodium bicarbonate 1-2 mEq/kg IV
  • Glucose-insulin combination
  • Lasix (increases excretion over hours)
  • Kayexelate 1 g/kg PR (not with sorbitol! Not to
    give PO for premies!)
  • Dialysis/ Exchange transfusion

27
Calcium
  • At birth, levels are 10-11 mg/dL. Drop normally
    over 1-2 days to 7.5-8.5 in term babies.
  • Hypocalcemia
  • Early onset (first 3 days)Premies, IDM, Asphyxia
    If asymptomatic, 6.5 Wait it out. Supplement
    calcium if
  • Late onset (usually end of first week)High
    Phosphate type Hypoparathyroidism, maternal
    anticonvulsants, vit. D deficiency etc. Reduce
    renal phosphate load

28
  • Monitoring fluid therapy
  • Wt loss 1 /d ( loss 2 /d dehydration / gain
    1 /d overhydration)
  • Urine 1-3ml/kg/hr ( 4
    overhydration / diuresis)
  • Na 135-145 mEq/L / K 4-5 mEq/ L
  • Osmolality 270-285 mosm/L
  • Urine sp.gr. 1005-1015
  • Blood glucose 60-100 mg/dl

29
Common fluid problems
  • Oliguria UOPPostrenal causes. Most normal term babies pee by
    24-48 hrs. Dont wait that long in sick lil
    babies! Check Baby, urine, FBP. Try fluid
    challenge, then lasix. Get USG if no response
  • Dehydration Wt loss, oliguria, urine sp.
    gravity 1.012. Correct deficits, then
    maintenance ongoing losses
  • Fluid overload Wt gain, often hyponatremia.
    Fluid sodium restriction

30
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31
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