fluid and electrolyte therapy hemant new.ppt

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

FLUID & ELECTROLYTE MANAGEMENT IN NEONATES

FLUID & ELECTROLYTE MANAGEMENT IN NEONATES

Fluid & Electrolyte Management in NeonatesFluid & Electrolyte Management in Neonates

Critical Aspect of

Care of High Risk Infants High frequency of parenteral fluid

administration

Variability in factors affecting the quantity &

composition of fluid requirement

Limitation in renal adjustment

Serious morbidities resulting from fluid &

electrolyte imbalance

0 3 6 9 // 0 3 6 9 0

20

40

60

80

100

60%

45%

26%

30%

42%36%32%

26%

Age in months

N e w- B o r n

TBW

ECW

ICW

TBW……ECF…..ICF

Perinatal Changes in TBW

Isotonic contraction of ECF -

physiological transition

Weight loss in 1st week of life

Term - 5 to 10%

Preterm 10 to 20%Can lead to imbalances in sodium and water homeostasis

Perinatal Changes in TBW

Isotonic contraction of ECF -

physiological transition

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 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

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


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.

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.


Pharmacologic agents like dopamine, increase urinary sodium losses

Fetal and postnatal kidneys exhibit diminished responsiveness to aldosterone compared to adult kidneys

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 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

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

Renal Function Status Related to F&E Management

Deficient concentrating & diluting capacity. Concentration Dilution

mosm / kg mosm / kg

Adults 1200 - 1500 50

Term 800 50

Preterm 600 70 Risk of dehydration Risk of volume overload

with fluid restriction with increased fluid intake

Renal Function Status Related to F&E Management

Deficient concentrating & diluting capacity. Concentration Dilution

mosm / kg mosm / kg

Adults 1200 - 1500 50

Term 800 50

Preterm 600 70 Risk of dehydration Risk of volume overload

with fluid restriction 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

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

Adult Term Preterm

Concen. capacity

Diluting capacity

1500 800 600

50

mOsmol/kg

Renal Prematurity cont…

Limited capacity….. CONCENTRATE and dilute urine

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

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

Failure to concentrate and dilute…..

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.

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.

Principles of F&E Therapy

3 components of F&E requirements Maintenance fluid Replacement of losses Replacement of current loss

More important in infant with diarrhea and dehydration, chest tube drainage, surgical wound, osmotic diuresis

Principles of F&E Therapy

3 components of F&E requirements Maintenance fluid Replacement of losses Replacement of current loss

More important in infant with diarrhea and dehydration, chest tube drainage, surgical wound, osmotic diuresis


Maintenance Fluid To replace physiologic losses

Insensible water loss (IWL) Renal water loss Stool water loss Sweat loss - Negligible in

newborns

Maintenance Fluid To replace physiologic losses

Insensible water loss (IWL) Renal water loss Stool water loss Sweat loss - Negligible in

newborns


Insensible Water Loss IWL is water that evaporates in

an invisible manner via skin

(2/3) or respiratory tract (1/3)

Most variable component of

fluid calculation

Various factors influence IWL

Insensible Water Loss IWL is water that evaporates in

an invisible manner via skin

(2/3) or respiratory tract (1/3)

Most variable component of

fluid calculation

Various factors influence IWL


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

Age (d) Birth wt (Kg)

0.75-1.0 1.0-1.5 1.5-2.0 0 - 7 65 55 - 40 20 - 15 7 - 14 60 50 - 40 30 - 20

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

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

Age (d) Birth wt (Kg)

0.75-1.0 1.0-1.5 1.5-2.0 0 - 7 65 55 - 40 20 - 15 7 - 14 60 50 - 40 30 - 20

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


Renal Water Loss Status of renal function

Renal solute load

Age Solute Water load req.for excretion mosm / kg / d ml / kg / d

< 1wk 5 20

> 2wk 15 - 20 60 - 80

Renal Water Loss Status of renal function

Renal solute load

Age Solute Water load req.for excretion mosm / kg / d ml / kg / d

< 1wk 5 20

> 2wk 15 - 20 60 - 80


Water for Growth 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.

Water for Growth 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.


Replacement of Deficit & Replacement of Current Losses

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

Replacement of Deficit & Replacement of Current Losses

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


Electrolytes

0 0.5 0.75 1.0 1.5 1.75 2 .0 2.5 3

Wt in Kg

8

7

6

5

4

3

2

1

Glucose GM%

2 mEq / 100 mlmE

q /

100

ml

4-5 m Eq/kg

<32 wks

Na

3 mEq/kg

10 gms / 100 ml5 gms/100ml

Electrolyte Requirement Maintenance Na & Cl after first 48

hours

Maintenance K after normal renal

function is ensured Requirement < 1wk 1 - 2 meq / kg / d

> 1wk 2 - 3 meq / kg / d

Maintenance Ca from day 1.

Electrolyte Requirement Maintenance Na & Cl after first 48

hours

Maintenance K after normal renal

function is ensured Requirement < 1wk 1 - 2 meq / kg / d

> 1wk 2 - 3 meq / kg / d

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

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

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

Common Parenteral Fluids…………….Common Parenteral Fluids…………….

SolutionGlucose

(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 368Isolyte-P 50 25 20 22 0 368

↑ Osmolality + ↑ Na

↓ Osmolality + ↓ Na

Maintenance Fluid Requirements

Initial fluid therapy

Birth Dextrose Fluid ml / kg / d wt (kg) conc. < 24 24-48 >48

< 1.0 5 % 100 120 140 1.0 - 1.5 10% 80 100 120 > 1.5 10% 60 80 120 Guidelines to be used as starting point Fluid requirement to be revised as per monitoring data

Maintenance Fluid Requirements

Initial fluid therapy

Birth Dextrose Fluid ml / kg / d wt (kg) conc. < 24 24-48 >48

< 1.0 5 % 100 120 140 1.0 - 1.5 10% 80 100 120 > 1.5 10% 60 80 120 Guidelines to be used as starting point Fluid requirement to be revised as per monitoring data


Increment…15 -20 ml /kg/day

Start….1st day……2.5-3.5 ml / kg / hr Add….0.5 ml to 1ml / kg /day

Wkend…..5-6 ml / kg / hr

Start….1st day……2.5-3.5 ml / kg / hr Add….0.5 ml to 1ml / kg /day

Wkend…..5-6 ml / kg / hr

Higher wt, Term …..lower requirementLower wt, Preterm ….. Higher requirement

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.

GLUCOSE REQUIREMENT 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

Glucose homeostasisStep 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

Glucose homeostasisStep 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


Markers for Appropriate Fluid & Electrolyte Balance

U.O. 1 - 3 ml / kg / hr Wt loss - Term 5% Preterm 15% Urine specific gravity

1.008 to 1.012 Normal S.electrolytes Postnatal growth chart

Markers for Appropriate Fluid & Electrolyte Balance

U.O. 1 - 3 ml / kg / hr Wt loss - Term 5% Preterm 15% Urine specific gravity

1.008 to 1.012 Normal S.electrolytes Postnatal growth chart


Postnatal growth Chart

Weight changes during first 50 days of life

Postnatal growth Chart

Weight changes during first 50 days of life


Perinatal Asphyxia Oliguria / anuria due to SIADH or ATN

Restrict fluid intake during the period of reduced 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

Perinatal Asphyxia Oliguria / anuria due to SIADH or ATN

Restrict fluid intake during the period of reduced 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


RDS 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

RDS 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


PDA

Restrict fluids to 2/3 the

maintenance requirement

PDA

Restrict fluids to 2/3 the

maintenance requirement


Diarrhea & Dehydration Dehydration of acute onset and short duration requires

more rapid correction Principles of fluid therapy similar to older infants &

children Fluid deficit volume judgement from acute weight

changes & degree of dehydration (More difficult to assess in preterms ) Replacement

50% water deficit - 1st 8 hours 50% water deficit - next 16 hoursNa deficit - 24 hoursK deficit - 48 - 72 hours

Diarrhea & Dehydration Dehydration of acute onset and short duration requires

more rapid correction Principles of fluid therapy similar to older infants &

children Fluid deficit volume judgement from acute weight

changes & degree of dehydration (More difficult to assess in preterms ) Replacement

50% water deficit - 1st 8 hours 50% water deficit - next 16 hoursNa deficit - 24 hoursK deficit - 48 - 72 hours


Sick & Critically Ill Neonates Provide fluid & electrolyte replacement as per state of hydration & circulatory status Third space losses difficult to quantify & replace. No contribution to fluid & circulatory dynamics

Sick & Critically Ill Neonates Provide fluid & electrolyte replacement as per state of hydration & circulatory status Third space losses difficult to quantify & replace. No contribution to fluid & circulatory dynamics


NO COOK-BOOK

APPROACH

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 meta-analysis 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 20-50 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 monitoring…essential. “No cook book approach” Consideration of Restrictive strategy.

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 monitoring…essential. “No cook book approach” Consideration of Restrictive strategy.

Preterm…Abnormal Facies 4th G mother , vth bad obstetric, h/o…3 abortions, H/o PolyhydramniosH/o BA…..mild RDS…recovered…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 …polyuricHyponitremiaHypoKalemicHypochloremicMetabolic Alkalosis↑R ↑A

Autosomal recessiveAntenatal Diagnosis possible……K wasting Disorder…….

enin ldosteron

8days old …..Full Term baby….3.5kg….Severely Dehydrated ( 17% wt loss since birth)Didn’t respond to IV fluidRefractory to supportive t/tNo evidence of UTI, Obstructive uropathy

Lab…. ↓Na , ↑K ↓ pH, ↓HCO3, ↓pCO2

EVEN to A DOSE OF STEROIDES

↑ Sr Cortisol ↓17OH prog ↑ Sr Renin ↑ Sr Aldosteron

……CAH

Severe Dehy + Meta Acidosis +Hyponitremia+HyperKalemia

RESPONSE TO STEROIDS

Yes NO

• 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 Introduction to EBM [evidence based medicine] [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: 1618

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….


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…


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….


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: 1618

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 doing something merely because it hurts the

doctor’s pride to do nothing….


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….


CBM Confidence based medicine

Applies only to surgeons….


The choice is yours!

Thank you for your attention

fluid and electrolyte therapy hemant new.ppt

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