FLUID

& ELECTROLYTE MANAGEMENT IN NEONATES

Dr. Hemant Parakh. MD, DM(neonatology).

Introduction

Physiological facts and their clinical implications

Protocols and thumb rules F & E Clinical & Laboratory guidelines. Guidelines for specific conditions. Simple conclusions

Fluid & Electrolyte Management in Neonates

Critical Aspect of Care of High Risk Infants

v High frequency of parenteral fluid

administration
v Variability in factors affecting the quantity &

composition of fluid requirement

v Limitation in renal adjustment v Serious morbidities resulting from fluid &

electrolyte imbalance

K Na Body Water

100 92% Body Watercontent % 80

TBWECF..ICF
77%

60

40

20

F e t u s
3

66% 60% 45% 42% 32% 26% 36% 60% TBW

30%
26%

ICW ECW

N e wBorn
6 9 // 0 Age in months 3 6

0 0 9

Fluid & Electrolyte Management in Neonates

Perinatal Changes in TBW

v Isotonic contraction of ECF -

physiological transition
v Weight loss in 1st week of life

Term - 5 to 10% Preterm 10 to 20%

Can lead to imbalances in sodium and water homeostasis

Sodium balance in the newborn

Renal sodium losses are inversely proportional to gestational age Term infants have Fractional excretion of sodium = 1% with transient increases on day 2 and At 28 weeks- Fractional excretion of Sodium = 5% to 6% Preterm infants <35wks display negative sodium balance and hyponatremia during first 2-3 wks of life

Sodium balance in the newborn

Preterm infants may need 4-5mEq/kg of sodium per day to offset high renal losses Increased urinary sodium losses

hypoxia respiratory

distress hyperbilirubinemia ATN polycythemia diuretics.

Sodium balance in the newborn

Pharmacologic agents like dopamine, increase urinary sodium losses Fetal and postnatal kidneys exhibit diminished responsiveness to aldosterone compared to adult kidneys

Water balance in the newborn

Primarily controlled by ADH which enables water to be reabsorbed by the distal nephron collecting duct Stimulation of ADH occurs when blood volume is diminished or when serum osmolality increases above 285mOsm/kg Intravascular volume has a greater influence on ADH secretion than serum osmolality

Fluid & Electrolyte Management in Neonates

Renal Function Status Related to F&E Management

v

Deficient concentrating & diluting capacity.

Concentration mosm / kg 1200 - 1500 800 600
Risk of dehydration with fluid restriction

Adults Term Preterm

Dilution mosm / kg 50 50 70
Risk of volume overload with increased fluid intake

Limited capacity to concentrate or dilute urine, neither excrete and conserve Na. Esp.. Preterm babies limited tubular capacity to reabsorb Na. Limited capacity to acidify urine GFR gestational age

Renal Prematurity cont

Limited capacity.. and dilute urine

Adult
Concen. capacity Diluting capacity

Term
800

Preterm
600

1500

50
mOsmol/kg

Non-oliguric Hyperkalemia. K 1st 24-48 hrs even in absence of exogenous intake & renal dysfunction

K shift. ICF to ECF (Na-K ATP activity)

More Preterm more SHIFT

Antenatal steroids reduces NOK !!!

Beware of non-oliguric hyperkalemia ,

Serum K level <3.5

Ensure Adequate Urine output and Sr K.. Adding K .

Failure to concentrate and dilute..

Risk to develop.. Hypernitremia (Dehydration) Hyponitremia (Over-hydration) Hyperkalemia Acidosis

Babies < 30-32 wks gestn may continue to pass large amounts of dilute urine despite dehydration becoz of renal immaturity. Hence urine output and specific gravity maybe an unreliable indicator of fluid status in these babies.

Fluid & Electrolyte Management in Neonates

Principles of F&E Therapy

3 components of F&E requirements v Maintenance fluid v Replacement of losses v Replacement of current loss
More important in infant with diarrhea and dehydration, chest tube drainage, surgical wound, osmotic diuresis

Fluid & Electrolyte Management in Neonates

Maintenance Fluid
v

v
v

To replace physiologic losses Insensible water loss (IWL) Renal water loss Stool water loss Sweat loss - Negligible in newborns

Fluid & Electrolyte Management in Neonates

Insensible Water Loss

IWL is water that evaporates in an invisible manner via skin (2/3) or respiratory tract (1/3)
v

Most variable component of fluid calculation Various factors influence IWL

Fluid & Electrolyte Management in Neonates

Average IWL of Premature Infant (ml/kg/d)

Age (d) 0-7 7 - 14
v v v

Birth wt (Kg) 0.75-1.0 65 60 1.0-1.5 55 - 40 50 - 40 1.5-2.0 20 - 15 30 - 20

Higher surface area/body wt ratio Immature skin Increased skin vascularity

RR Breached skin (removal of adhesive tapes) Surgical malformations e.g.

(gastroschisis, omphalocele, neural tube defects)

Body temp : 30% High ambient temp: 30% Radiant warmer and phototherapy: 50% Ambient humidity.

Motor activity, crying: 50-70%

Use of incubators Humidification of inspired gases in head box and ventilators Use of Plexiglas heat shields Increased ambient humidity

Thin transparent plastic barriers

Applying oil / ointment

Fluid & Electrolyte Management in Neonates

Renal Water Loss

v Status of renal function v Renal solute load

Age

Solute
load

Water
req.for excretion

mosm / kg / d < 1wk > 2wk 5 15 - 20

ml / kg / d 20 60 - 80

Fluid & Electrolyte Management in Neonates

Water for Growth

v

Water required for formation of new tissue in growing infant.

20 to 25 ml / kg / day as infant grows at rate of 25 to 30 g / kg / d & the new tissue contains 70% water.

Fluid & Electrolyte Management in Neonates

Replacement of Deficit & Replacement of Current Losses

Measure the volume & composition of abnormal fluid loss & replace volume per volume & mole per mole basis

Glucose GM%

10 gms / 100 ml

5 gms/100ml

8 7 6 5 mEq / 100 ml

4
3 2 1 0

Electrolytes
2 mEq / 100 ml
0.5 0.75 1.0 1.5 Wt in Kg 1.75 2 .0 2.5 3

Fluid & Electrolyte Management in Neonates

Electrolyte Requirement
v Maintenance Na & Cl after first 48

hours
v Maintenance K after normal renal

function is ensured
v Requirement < 1wk

> 1wk

1 - 2 meq / kg / d 2 - 3 meq / kg / d

v Maintenance Ca from day 1.

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

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

Common Parenteral Fluids.

Solution 10% Dextrose 5% Dextrose (D5W) Glucose Na+ (g/L) 100 50 0 50 50 50 0 0 154 154 77 38 K+ 0 0 0 0 0 Cl0 0 154 154 77 38
Lactate mOsm/l

0 0 0 0 0 0

500 250 308 560 406 320

0.9% Normal Saline (NS)

D5 0.9NS D5NS ( 0.45%) D5NS(0.2%)

Isolyte-P Isolyte-P

50 50

25 20 20 22 22 25

0 0

368 368

Serum Na / Osmolality
(Na levels often reflect fluid status rather than Na intake)

Osmolality + Na

Osmolality + Na

wt loss.. Dehydration wt gain..Salt + water load wt lossNa depletion wt gainOver-hydration

Urine volume..
<1ml /kg /hr requires investigation 2- 4ml /kg /hr suggests normal hydration >6- 7ml /kg /hr excess fluid Administration i.e. Over-hydration

Fluid & Electrolyte Management in Neonates

Maintenance Fluid Requirements

Initial fluid therapy
Birth Dextrose wt (kg) conc. < 1.0 5% 1.0 - 1.5 10% > 1.5 10%
v v

Fluid ml / kg / d < 24 24-48 >48 100 120 140 80 100 120 60 80 120

Guidelines to be used as starting point Fluid requirement to be revised as per monitoring data

Day 1

Day 6-7 Increment 15 -20 ml /kg/day

< 1 kg
1-1.5 kg >1.5 kg

100
80 60

150
150 150

Start.1st day2.5-3.5 ml / kg / hr
Add.0.5 ml to 1ml / kg /day

Wkend..5-6 ml / kg / hr
Higher wt, Term ..lower requirement Lower wt, Preterm .. Higher requirement

TO KEEP IN MIND. Clinical implications.!!!

Total fluids are calculated based on Birth Weight till the Neonates becomes HEAVIER than birth weight

Postnatal Day 1
H2 O

25 - 27 wk: 120 mL/kg/d 28 - 30 wk: 100 mL/kg/d 31 - 36 wk: 80 mL/kg /d >36 wk: 60 mL/kg /d

Prediuretic Phase <25 wk: 150 mL/kg /d Increase if

wt loss is >2%/d or sr Na

Diuretic/ Natriuretic Phase

by 15 to 20 mL/kg/ d Ifwt loss > 5%/d OR Sr Na >150 mEq/L vth no Na intake by 15 to 20 mL/kg /d ifwt loss <1%/d

Decrease if
wt or Sr Na

Na

None

Usually no Na required

Begin 1 to 2 mEq/kg/d If Sr Na <135 mEq/L vth wt loss or Sr Na is <130 mEq/L vth no change or gain in wt
Begin 1-2 mEq/kg/d.<5 & not sing & UOP>1ml/kg/hr

None

Usually no K required

Lorenz JM. Fluid and electrolyte therapy in the newborn infant. In: Burg FD, Polin RA, Ingelfinger JR, Gershon A, eds.Current Pediatric Therapy 17. Philadelphia, Pa: WB Saunders; 2002.

INCREASE I/V fluids..

..wt loss (> 3% / day)

..Sr Na > 145 mEq/L

..Specific gravity >1.020

..urine osmolality >400 mosm/L

..urine output < 1ml /kg/hr

DECREASE I/V fluids..

..wt loss (1<% / day) ..wt gain + Sr Na (< 130 mEq/L)
..Specific gravity < 1.005 ..urine osmolality <100 mosm/L ..urine output >3ml /kg/hr

GLUCOSE REQUIREMENT

Optimum requirement 4-6 mg / kg / min

Conc. Used - 5%, 10%, 12.5% (max)

Glucose infuse (mg / kg / min) = % Gx rate (ml / hr.) x 0.167 x wt. Thumb rule 3 ml / kg / hr of 10% D = 5mg / kg / min Remain careful about glucose in LBW

IDM
IUGR

Fluid & Electrolyte Management in Neonates

Glucose homeostasis
Step 1 : Calculation of GIR GIR (mg / kg / min) = Fluid rate (... /kg / day) X 0.07 Eg. If rate of fluid is 100 ml / kg /d of 10% D GIR = 100 X 0.07 = 7 mg / kg / min Step 2 : Increasing GIR by 1 mg / kg / min Add 2 ml / kg of 25% D to each 8 hr drip Eg. from 7mg / kg / min GIR will increase to 8 mg / kg / min

Fluid & Electrolyte Management in Neonates

Markers for Appropriate Fluid & Electrolyte Balance

v U.O. 1 - 3 ml / kg / hr v Wt loss - Term 5%

Preterm 15% v Urine specific gravity 1.008 to 1.012 v Normal S.electrolytes v Postnatal growth chart

Fluid & Electrolyte Management in Neonates

Postnatal growth Chart Weight changes during first 50 days of life

Fluid & Electrolyte Management in Neonates

Perinatal Asphyxia
Oliguria / anuria due to SIADH or ATN
v Restrict fluid intake during the period of reduced

v
v v v

UO to avoid fluid overload. Restore fluid intake to normal level when UO is normal (D3). Avoid K during oliguric phase. Give crystalloid 10 ml / kg ( if cause of anuria is unclear) Administer low dose dopamine and lasix if required

Fluid & Electrolyte Management in Neonates

RDS
v

Prediuretic phase (Stabilization phase) Fluid restriction Treat shock Prevent hypoglycemia Diuretic phase (Restriction maintenance phase) Continue 2/3 restriction Prevent dehydration Postdiuretic phase (Liberalization phase) Give full maintenance

Fluid & Electrolyte Management in Neonates

PDA
v Restrict fluids to 2/3 the

maintenance requirement

Fluid & Electrolyte Management in Neonates

Diarrhea & Dehydration

v Dehydration of acute onset and short duration requires

more rapid correction v Principles of fluid therapy similar to older infants & children v Fluid deficit volume judgement from acute weight changes & degree of dehydration (More difficult to assess in preterms ) v Replacement 50% water deficit - 1st 8 hours 50% water deficit - next 16 hours Na deficit - 24 hours K deficit - 48 - 72 hours

Fluid & Electrolyte Management in Neonates

Sick & Critically Ill Neonates

v Provide fluid & electrolyte

replacement as per state of hydration & circulatory status

v Third space losses difficult to

quantify & replace. No contribution to fluid & circulatory dynamics

Diarrhoea ..Maint + ongoing loss Int. obstrnMaint + R/T loss NEC200ml/kg

PDA120ml/Kg
BPD120ml/kg ARF400ml/m2 + urine output Monitor therapy in all situations

There has been a lot of interest in the amount of fluid therapy and outcome of preterm neonates in terms of mortality and morbidity. The Cochrane metaanalysis on this topic could identify four eligible studies. Their findings state that, although restricted fluid therapy may lead to greater weight loss and dehydration, it is associated with a decreased incidence of death, PDA and NEC. There also seems to be a beneficial effect of restricted fluid therapy on the incidence of BPD.

The volume of fluids used in the restricted groups differs from the above-described fluid therapy by 2050 ml/kg/day in the initial 3-4 days. Based on their meta-analysis, the investigators had concluded that fluid therapy needs to be balanced enough to meet the normal physiological needs without allowing significant dehydration.
Bell EF, Acarrgui MJ. Restricted versus liberal water intake for preventing morbidity and mortality in preterm infants. Cochrane Database Syst Rev 2000,(2):CD000503

Maintenance Fluid 1st day.2.5-3.5ml/kg/hr. Volume 5-6ml/kg/hr by wkend. Electrolytes after 48 hrs. Add K after pee Frequent clinical/ Lab monitoringessential. No cook book approach Consideration of Restrictive strategy.

PretermAbnormal Facies 4th G mother , vth bad obstetric, h/o3 abortions, H/o Polyhydramnios H/o BA..mild RDSrecovered Persistantly Dehydrated (s/o volume depleted..BP) Still Polyuric.. difficult to correct Lab: Urine. Ca +++ Electrolytes ( Na, K, Cl, N..Mg), ABG .pH, HCO3, pCO2 Key LAB report ..1. R. 2.A USG Nephrocalcinosis

A Poor Dehydrated Baby.

Triangular Face

Prominent Forehead
Large eyes

Strabismus
Protruding ears

Preterm PolyHydramnios polyuric Hyponitremia HypoKalemic Hypochloremic Metabolic Alkalosis R enin A ldosteron

Autosomal recessive Antenatal Diagnosis possible K wasting Disorder.

8days old ..Full Term baby.3.5kg. Severely Dehydrated ( 17% wt loss since birth) Didnt respond to IV fluid EVEN to A DOSE OF STEROIDES Refractory to supportive t/t No evidence of UTI, Obstructive uropathy Lab. Na , K pH, HCO3, pCO2
Sr Cortisol 17OH prog Sr Renin Sr Aldosteron

Severe Dehy + Meta Acidosis + Hyponitremia+ HyperKalemia

CAH

Yes

NO

PHA

 Pseudohypoaldosteronism (PHA) refers to a group of disorders characterized by apparent renal tubular unresponsiveness to aldosterone as evidenced by hyperkalemia, metabolic acidosis, and variable degrees of renal sodium wasting. PHA has two major subtypes. Type I usually manifests in infancy with hypotension, severe sodium wasting, and hyperkalemia. Type II (Gordon syndrome) typically manifests in late childhood and adulthood.

Introduction to EBM [evidence based medicine]

Can you intubate?

Alternatives to EBM
At least 7
EBM, Eminence Based Medcine EBM, Eloquence Based Medicine VBM, Vehemence Based Medicine PBM, Providence Based Medicine DBM, Diffidence Based Medcine NBM, Nervousness Based Medicine CBM, Confidence Based Medicine

Isaacs D, Fitzgerald D. BMJ 1999; 319: 16

EBM Eminence based medicine

The more senior the colleague, the less importance (s)he placed on the need for anything as mundane as evidence.

Making the same mistakes with increasing confidence over an impressive number of years.

Isaacs D, Fitzgerald D. BMJ 1999; 319: 16

EBM Eloquence based medicine

The year round suntan, carnation in the button hole, silk tie, Armani suit, and tongue.
Sartorial elegance and verbal eloquence are powerful substitues for evidence

Isaacs D, Fitzgerald D. BMJ 1999; 319: 16

VBM Vehemence based medicine

The substitution of volume for evidence
..is an effective technique for brow beating your more timorous colleagues and for convincing relatives of your ability.

Isaacs D, Fitzgerald D. BMJ 1999; 319: 16

PBM Providence based medicine

If the caring practitioner has no idea of what to do next, the decision may be best left in the hands of the Almighty.

Too many clinicians, unfortunately, are unable to resist giving God a hand with the decision making.

Isaacs D, Fitzgerald D. BMJ 1999; 319: 16

DBM Diffidence based medicine

Some doctors see a problem and look for an answer. Others merely see a problem. The diffident doctor may do nothing from a sense of despair..

This, of course, may be better than doin something merely because it hurts the doctors pride to do nothing.

Isaacs D, Fitzgerald D. BMJ 1999; 319: 16

NBM Nervousness based medicine

Fear of litigation is a powerful stimulus to overinvestigation and overtreatment.

In an atmosphere of litigation phobia, the only bad test is the test you did not think of ordering.

Isaacs D, Fitzgerald D. BMJ 1999; 319: 16

CBM Confidence based medicine

Applies only to surgeons.

Isaacs D, Fitzgerald D. BMJ 1999; 319: 16

The choice is yours!

Thank you for your attention