WORKSHOP on NEONATAL FLUID ELECTROLYTE THERAPY Presented B

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

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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 ECF 40 -
Newborn 20 - Older Children
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WHO REQUIRE FLUID
q Infant lt 30 wks. lt1250 gm.   q
Sick Term Newborns - Severe birth
asphyxia - Apnoea - RDS -
Sepsis - Seizure
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HOW MUCH FLUID TO BE GIVEN

• lt1 kg 1-1.5 kg. gt1.5 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.
• q All 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. lt1 kg - 5 Dextrose 1-1.5
kg. - 10 Dextrose gt1.5 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
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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 q Allow 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 100 ml / day
q 25 ml 6 hourly
q 10 Dextrose 4 ml / hr 4drops / 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 lt 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
lt1500 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

• q Optimum 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 gt 3 -
dehydration lt1 over dehydration q
Urine output lt1 ml / kg / hr dehydration or
SIADH (Hourly) gt4 ml / kg / hr.
overhydration / dieresis Napkin weight
technique Collect in syringe from
cotton   q Urine specific gravity gt1015
fluid deficit (each sample if possible)
lt1005 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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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 lt100 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
•   q Diagnosis
• q Management

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CASE.
- A 30 yrs Woman P2o 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
q Serum Na lt130 mEq / lit q Neurological Signs
or Na lt120 mEq / lit ? treat promptly q
What 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.
q How 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.  
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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 Nagt 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 gt10 mEq / lit
/ day. -- May require 3 NaCl if
over correction leads 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 gt plasma osmolality   Treat ?
q Water restriction 2/3 maintenance x 24 hrs
q 3 Nacl if Na lt120 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 gt 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 gt 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

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Commercial electrolyte and dextrose stock sol.
Solution Concentration Available from Equivalents
Soda bicarb solution 7.5 10 ml ampoule 1 ml 1 mEq of HCO3 1 mEq of Na
Potassium Chloride 15 w/v 10 ml ampoule 1 ml 2 mEq of K
Calcium gluconate 10 w/v 10 ml ampoule 1 ml 9.3 mg of Cal.
Magnesium sulphate 50 and 25 2 ml ampoule If 25 Mg 4.15 mOsm/dL
Sodium Chloride 3 10 ml ampoule 50 ml bottle 1 ml 0.5 mEq of Na
25 Dextrose 25 w/v 25 G/100 ml 10 ml ampoule and 25 ml ampoule
50 Dextrose 50 w/v 50 G/100 ml 25 ml ampoule
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Composition of commercial i.v. fluid available
Dextr. Na K Cl Lactat Ca mOsm/L
G/L
Isotonic NS 154 154 308
RL 131 5 111 29 2 270
½ isotonic ½ NS 77 77 154
Electrolyte free solution 5 50 278
Electrolyte free solution 10 100 556
Dextrose, electrolyte solution 5 DNS 50 154 154 585
Dextrose, electrolyte solution D5 ½ NS 50 77 77 415
Dextrose, electrolyte solution D5 0.33 NaCl 50 57 57 381
Dextrose, electrolyte solution D5 0.2 NaCl 50 34 34 347
Ped. Maint. Isolyte P 50 25 20 22 368
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HYPOCALCAEMIA
 Serum calcium lt7.0 mg / dl ionised cal lt4.0 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
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HYPOCALCAEMIA 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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Thank U