IV Fluid Therapy in Neonate

Introduction: The requirements for fluids and electrolytes of the newborn infant are unique. Fluid administration in neonates differs greatly from that of adult patients because of the need for weight-based dosing and the resulting need for individual dose calculation. At birth, there is an excess of extra-cellular water (ECW), and this decreases over the first few days after birth. Insensible water loss is a major portal of fluid loss which decrease as birth weight and gestational age increase. Several days after birth, fluid and electrolyte requirements increase as the infant starts to grow. Therefore, appropriate management of fluids and electrolytes in preterm infants must take into consideration the birth weight, gestational age and postnatal age. Indications for starting intravenous fluids GA < 32 wks or birth weight < 1250g Sick neonates with Respiratory distress Severe Birth asphyxia Recurrent apnea Seizures Intestinal obstruction Ileus / Necrotising Entero Colitis Shock Dehydration

In very immature infants urine output is variable. Stool water loss is small and usually less than 5 ml/kg/day in the first days after birth. The fluid requirements in ml/kg/d are approximately Birth weight Day 1 Day 2 Day 3 Day 4 Day 5 <1000 g 1-1.5 kg >1.5 kg 100 Subsequently advance fluids acc. to hydration status

80 100 120 140 150 60 80 100 120 140 Always start maintenance IVF on day of admission and subsequent advances should be made only after assessment of fluid status. General concepts regarding electrolytes Give sodium free fluid on day 1 of life. Start when cumulative weight loss from birth reaches 6% or serum sodium falls to 130 mEq/l. Potassium is generally added from day 3 of life after ensuring adequate urine output of 1ml/kg/hour and K < 5.5 meq/l. calcium can be added from day 1 of life and should be given to all sick babies and babies <1500g. Please note : Babies with gestational age <32weeks continue to pass large amounts of urine despite dehydration because of renal immaturity. Hence, urine output as a marker of dehydration is an unreliable indicator in this group of babies. General guidelines for adjustments of IVF Increase maintenance IVF by 20ml/kg/day everyday till a maximum of 150 ml/kg/day. Additional allowances of 20ml/kg/day can be given for radiant warmer and phototherapy. Calculation of output: urine output is the second major portal of fluid loss in initial days. It is always calculated as ml/kg/hr and should be calculated every 6hrly in a sick neonate. Urine out put > 5 ml/kg/hr is called polyria. Urine out put < 1 ml/kg/hr is called oliguria Urine out put < 0.5 ml/kg/hr is called anuria. Measures to reduce insensible water loss Ensure humidified air during ventilation & oxygen therapy. Evaporative loss may be up to 6 times higher per unit surface area in ELBW baby in comparison to a term baby. Try to reduce insensible water losses to

minimum. Nurse babies in incubators as far as possible. Use double walled incubators or plexiglass heat shield in ELBW babies. Keep babies clothed with a cap. Avoid placing open care system near entrance & vents. Maintain thermoneutral environmental temperature. Set desired temperature in servo-controlled mode to 36.5C. Clings wrap : Food grade plastic film can be stuck edge to edge just above the infant in an open care system. Create a microenvironment by clean plastic film which prevents about 30% of IWL. Oil application can be a method of reducing insensible water loss. Avoid skin injury while removing adhesive tapes. Fluid charting Fluid recharting should be done every 6-12 hourly based on assessment of fluid status. Always use infusion pumps for continuous infusions. While calculating fluid volume, volume of blood products must be deducted from the total fluid volume. Drugs like calcium gluconate, vancomycin can amount to a substantial volume especially in small babies. Hence their volume should be deducted from the total fluids. J Always seek permission and guidance from the treating doctor before starting, making any adjustments, adding electrolytes in IVF and also for undertaking oil application. Preparation of IVF Maintaining aseptic precautions is the most important and useful step in fluid management as it can be a major source of infection. Wash hands thoroughly before preparation of IVF. Create a clean surface (by spreading either an autoclaved drawsheet or gown). Always use disposable syringes and tubings. Wear gloves (may use sterile paper gloves). Use syringes with luer lcok for giving IVF. Avoid multiple joints in tubing. Avoid mixing any drug in IVF.(Unless doctor ordered.) Use separate port for (preferably separate IV line) for giving injectable drugs. Change IVF tubings everyday.

When certain electrolytes or dextrose are to be added to particular fluids please make sure and double check the amount specified in orders. Newborns can be harmed if improper dosing / addition is done. Whenever a new formula is prepared by addition of something to principle fluid please label that describing the equation/formula.

Calculating the fluid drip rate manually (when infusion pump is unavailable): When infusion pumps or syringe pumps are unavailable the nurse has to use micro drip set or special pediatric infusion micro drip set (eg. PediaDrip). If a IVF rate is 1ml / hr , set 1 micro drop/ min in the micro drips or pediatric drip set. Eg. For a baby if you have to start a fluid 10ml/hr start micro drip @ 10micro

drops / min. References: 1. ACORN Manual : First Edition, Chapter 7 / Fluid & Glucose management ,2007. 2. AIMS NICU Protocols fluid & electrolytes, Deepak Chawla, Ramesh Agarwal, Ashok Deorari, Vinod K Paul : 2008.