Fluid & Elecrolytes

Management In
Newborns

DR.MAULIK SHAH MD.(PED)

ASSOCIATE PROFESSOR OF
PEDIATRICS
M.P.SHAH MEDICAL COLLEGE,
JAMNAGAR.
 EXTRA CELLULAR
cell INTRA CELLULAR
interstitium cell
fluid

fluid
ve sse
 EXTRA CELLULAR fluid
INTRA CELLULAR fluid

cell interstitium
vessel
 100
92% TBW……ECF…..ICF
77%
o d y W a t e r c o80n t e n t %

Fetus60% 66%
60% TBW
60
45%
42%
40 32% 36%
30% ICW
26%
ECW
20 N e w- 26%

B o r n
0
0 3 6 9 // 0
3 6 9
Age in months
Changes during delivery &
labour

cell interstitium cell

vessel
Why Newborn / preterm babies have large
amount of water than older infants ?
Why Preterm babies loose more wt
than term babies?
Where does the water go ?
• SENSIBLE loses
 means - measurable sources
Examples

• Urine
• stool (diarrhea and ostomy)
• naso/oro gastric drainage
• or any other loss .
 Where does the water go ?
• INSENSIBLE
IN loses
 means - UNmeasurable sources


Through…


• Skin
• Respiratory mucosa
•
In Sensible Water Loss(IWL)
• Key Variable.
• Shared: The skin- 2/3 + Respiratory
tract -1/3.
• IWL….inversely  to…
1. Gestational Age (more preterm: more

IWL)
2. Postnatal age

(skin thickens with age: older is better

--> less IWL)

 C lick to e d it M a ste r title
style
Stratum corneum
• The outer most
layer of cells
which form
theepidermal
barrier:
• - 10-20 layers in
full term infants
• - 2-3 layers at 30
weeks
gestational age
• - Virtually no layers
 What increases IWL ?
• ↑ RR
• Radiant warmer and phototherapy: 50%
• High ambient temp: ↑ 30%
• Breached skin (removal of adhesive tapes)
• Surgical malformations e.g. (gastroschisis,
omphalocele, neural tube defects)
• Body temp : ↑ 30%
• ↓ Ambient humidity.
• ↑ Motor activity, crying: 50-70%

Why to prevent IWL ?

cell interstitium cell

ve sse l

Na

Na

Na Na
Na
How to reduce IWL
 How to reduce IWL ?

1
2

• non-abrasive tape such as

Micropore®.
4
• Use of Tegaderm or Duoderm
adhesives.
3

• semipermeable membranes beneath

a.neonatal electrodes
b.urine bags,
c.transcutaneous oxygen electrodes
 Adhesives & Skin
• Adhesive removal is the primary cause of skin
breakdown.
• Recommended Practices
– Applying Adhesive
• Minimize amount of adhesive in contact with skin
• Use smaller pieces of tape
• Use “double-backed” tape
• Deactivate adhesive with cotton balls when full
adhesion not required
• Do not use bonding agents (benzoin) to enhance
adhesion
• Avoid bandages after heel sticks. Use pressure
with a cotton ball or gauze 
– Removing Adhesive
 C lick to e d it M a ste r title
style
How to reduce IWL
• Humidification
of inspired
gases in head
box and
ventilators
How to reduce IWL ?
 How to calculate IWL ?
• IWL = Fluid intake
 - Urine output
 + weight loss (or – weight gain)
Eg. 3 kg baby onD-2 : 60ml/kg +

20ml/kg for RW
 = 240 ml intake
 - 50 ml urine out put
 -30 gm wt. gain
 so total : 160 /3 = 53 ml / kg IWL
 How to utilize IWL
measures?
Eg. 3 kg baby on day 2 : 200 ml
intake
 53 ml / kg
IWL


Intake was planned - 60ml /kg

As a routine next would be – 75ml/kg

But baby is retaining fluid – so ideal

 C lick to e d it M a ste r title
style
So how much water to put
back?

 GROWTH

Replacement
 of Blood transfusions
loss IV Pushes

a. endogeous water produced

b. In Sensible Water
Loss
c. Sensible water
loss



 The Fluid Equation
Sensible
Insensible Water Loss Water Loss Growth

<1 kg……..…90-100 Urine

1- 1.5 kg…...60-70 25-75ml /d 25-30ml /d
>1.5 kg ……40-50

Stool
15-30ml /kg
Fluid requirements……VOLUME….

Day 1 Day 2-3 Day 4-5 Day 6-7

< 1 kg 80-100 120 140 150

↑ ↑ ↑
1-1.5 kg 80 15 -100
20 ml15 20 ml15
/ kg-120
/ day 20 ml / kg / day
/ kg-150
/ day

>1.5 kg 60 80 110 150

Why do all the newborns
– preterm or full term
require same amount at
1 week age…?
B’cause – stratum corneum
matures
 Basic Principles for Fluid
Prescription
• The birth weight to be taken in
consideration till baby grows beyond.
• Add extra for the conditions which
increase
 IN-SENSIBLE or SENSIBLE loses.
eg. 20ml/kg for photo therapy or

radiant warmer.
• Final total volume calculated for 24 hrs.
 Restricted versus liberal water
intake
“ restriction of water intake so that


physiological needs are met without

allowing significant dehydration is
expected to decrease the risks of
PDA and NEC without significantly
increasing the risk of adverse
consequences.”
-
 Prescribing Fluid Therapy
• Baby … Birth weight ….. Day of Life
• Total volume = basic fluid (ml/kg)
 + Insensible loss of RW/Photo
 + Sensible loss of Aspirates / Drains

A ctu a lVused
- fluid o lu mused
e for
 # for dilution of drugs
 # I/V Pushes or boluses
 # Blood products transfusion


• Devide the volume in various sub heads

 I/V fluids m l@ h o u r
 Feed volume



 Changing Equations
Situation Recommendation

Watery diarrhoea Maintainance+ on going loses

(5ml/kg/freq )
Intestinal obstructions Maintainance + Aspirates + Drains

NEC 180 ml/kg

P.D.A. 100-120 ml/kg

Acute Renal Failure(established/ Renal) 400 ml/ m2 or 40ml / kg

C.L.D. 120 ml/kg

 Accuracy in prescription
• Write neatly.
• Use calculators.
• Show all steps of counting.
• Double check.
• Fluid rate always in ml/ hr… NOT
mg/kg/min
• Fluid orders to be designed for small
intervals.
 I am not fond of
calculation…!

But I am tech
savy…!

Calculators for your desktop

Click to edit Master title
style
Accuracy in Fluid Delivery
• Use of Infusion Pump for
I/V Maintenance.
• Use of Syringe Pump for
Drug infusions.
• Proper Input and Out put
Nursing Chart.
• If no gazets…use
Pediatric Drip sets.
 (ml @ hour = micro
drops /min)
Monitoring the Fluid therapy
• Daily weight
• Urine out put
• Other drains out put.(eg.NG)
• Vitals – blood pressure – signs of
Dehydration
Labs:

1.urine specific gravity / osmolality/

Na+
2.Serum Na+
• Day 18 –Baby wt 1250gm today
weight 1.3kg
• Under radiant warmer
• NG Aspirates = 5cc last 24hrs
• On half ivfluid and NG tube feeding
40cc/kg
• Planned for a PCV transfusion 20 cc
today.
• Prescribe fluid & feed plan.
• 22
 Electrolytes Prescription
• Day 1 - 2: 10% dextrose


• Day 3 onwards : + Electrolytes

 Na….3mq/kg/day
 K ……2mq/kg/day
 (ensure adequate
U/O)


• Ped. Maintenance: 5-10%D+ 1/6 N

 Parenteral Fluids
Solution Glucose (g/L) Na+ K+ Cl- Lactate mOsm/l

10% Dextrose 100 0 0 0 0 500

5% Dextrose (D5W) 50 0 0 0 0 250

0.9% Normal Saline (NS) 0 154 0 154 0 308

D5 0.9NS 50 154 0 154 0 560

D5½NS ( 0.45%) 50 77 0 77 0 406
D5¼NS(0.2%) 50 38 38 0 320
Isolyte-P 50 25 20 22 0 368
 Hyper Natremia
Due to Excessive water loss


• Insensible loss
üin Summers
üdue to inadequate feeding
üunder radiant warmer
üOpen body defects
• Sensible loss
ü in extreme prematures
ü diarrhoea
 Hyper Natremia

Due to excess of Sodium



ü Breast Milk hypernatremia

ü Iatrogenic – Soda bicarbonate use.
ü In drug formulas
ü Improper dispension (eg ORS).
•
Click to edit Master title
style
Hyponatremia
• Diuretics • Inappropriate
• glycosuria Secretion of
• renal water and Antidiuretic
sodium wasting Hormone (SIADH)
(VLBW) Tre a tin g a cu te p h a se :
• adrenal and renal < 125 mEq / L or
tubular disorders S ym p to m a tic
• GI Losses and third 1 m l/ kg o f 3 % N a C l
spacelosses of ECF ( ( 0 . 5 meq / ml
skin sloughing, early
D o se … 4 m l/ kg o ve r 2 -3
 Hyper Kalemia [K+] >6
mEq/L)
• Non oliguric hyperkalemia (ELBW)

Increasing Serum K+
• Acute Renal Failure
• Acidosis
• Cong.Adrenal Hyperplasia
• Intra ventricular Hemorrhage
• blood transfusion (>7 days stored)

Newborns are usually resistant to cardiac arrythmia from

Hyper kalemia.
Click to edit Master title
style
Treatment for Hyper
kalemia
 Membrane
Stabilization (↓ Enhanced Elimination


membrane
excitability) § Kayexalate
§ IV calcium 1-2
§ Loop
cc/kg (10%)
l diuretic..Lasix
 Internal § Peritoneal
Redistribution
§ IV insulin dialysis
glucose drip
§ IV NaHCO3
§ Exchange
 Friends, Let’s Share our views….


DR . MAULIK SHAH MD .( PED )

ASSOCIATE PROFESSOR OF PEDIATRICS
M.P.SHAH MEDICAL COLLEGE,
JAMNAGAR.
maulikdr@gmail.com
Visit :
http://matrutvanikediae.blogspot.com

a maulik shah presentation