WHY THIS BORING TOPIC

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WHY THIS BORING TOPIC

• q Intake of Sick Newborn at the mercy 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 25ml 25 D
75ml ISO P ? Na - 22.7 mEq / lit K
- 18 mEq / lit Cl - 22 mEq /
lit 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 80 ml / day q 20 ml 6
hourly q 10 Dextrose 3.5ml / hr 3 drops /
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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Peripheral lines Indications Purpose

• Maintain fluid, electrolyte acid-base balance
  in neonate
• Provide IV medications.
• Provide blood or blood components.
• Provide peripheral parenteral nutrition.
• N B do not try gt 2consecutive times by the same
  person !

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Preliminary steps
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Insertion of Line
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Monitoring Discontinuation

• Observe rate, patency ,air within the line.
• Observe for local warmth, pain,leak redeness
  ,edema, blanching.
• Flush with 2 ml N.Saline (with asepsis) if needed
  to check the line.

• Indication on order / leak / phlebitis /
  thrombosis / blanching (except with ionotrope
  infusion).
• Stop fluid / asepsis / remove dressings / remove
  cannula / press until bleeding stops / dress with
  iodine.
• Send cannula tip for culture if phlebitis.

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Umbilical venous line

• Purpose Central line for medication, exchange
  transfusion, pressure monitoring and fluid
  (rarely)
• Policy Should be done by a doctor only.
• Emphasis Tip in ductus/IVC, do not advance once
  secured, do not keep open, very careful about
  sepsis.
• Equipment 5Fr for lt 3.5 kg 8Fr for gt 3.5kg.(
  It should have side holes at tip ), forceps,
  scalpel,probe, suture, drapes, asepsis utensils,
  tapes, ties etc. )

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UVC Procedure

• Estimate length of the catheter(graph), assemble
  equipments
• Universal asepsis.
• Identify UV( patulous, single, bleeding, at 12
  oclock) / grasp cord with toothed forceps /
  remove clots from vein by iris forcep
• Introduce fluid filled catheter with stop cock
  2-3 cm inside vein / suck for blood / remove clot
  if no free flow of blood /remove, rotate
  reinsert until free flow comes / advance to
  desired length
• Fix UVC once free flow established with tapes.
  Radiology confirmation (D9-D10 or just above
  right diaphragm).

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Capillary Blood Sampling

• Purpose heel prick blood sampling
• Emphasis safe and effective / maxm. 2 pricks
  per heel (except sick newborn).
• Policy preferably doctors/ only trained nurse.
• Indications sugar / blood gas / Hct / sepsis
  screen / bilirubin / biochemistry.
• Equipment asepsis utensils, lancet, capillary
  tubes, gauze.

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Procedure of CBS

• Ask sister to bundle the neonate. Chose the site
  (picture). Warm the area with dry warm cloth.
• Universal asepsis. Perform lancet puncture in
  most medial or lateral aspect of plantar surface
  (avoid puncture on previous or previous weight
  bearing sites of the neonates).
• Discard first drop of blood / hold the site
  downward / keep gentle continuous pressure /avoid
  milking / Collect in capillary tube /
• Stop bleeding by pressure / apply Iodine / label
  each tube / send with details quickly / document
  all details.

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Special situations
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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 - Co 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
• - Salbatatnoe Nebalisation 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.
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Composition of commercial I.V. fluid available
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HYPOCALCAEMIA
 Serum Calcium lt7.0 mg / dl Ionised Cal lt4.0 mg /
dl Seizure Treatment of Hypocalcaemic
Crisis apnoea Tetaxy 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 Refactory 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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