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Fluid electrolyte management in newborn

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Pediatrics

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Fluid electrolyte management in newborn

  1. 1. FLUID AND ELECTROLYTE MANAGEMENT IN NEWBORN By Dr B VIKRAM SIMHA Guide: Dr SANJAY CHATTREE
  2. 2. AIM : to allow successful transition from the aquatic environment of the uterus into the arid extra-uterine milieu in the first days of life and to replace losses of water and electrolytes so as to maintain normal balance of these essential substances.
  3. 3. PHYSIOLOGICAL ASPECTS: Urine osmolarity range : 50mmol/L to 600mmol/L (Preterm) and 800mmol/L(Term) Acceptable Range : 300-400 mmol/L  2-3ml/Kg/Hr of UOP Neonatal Kidney has limited capacity both to excrete and conserve Sodium-so Na+ Supplementation required. Newborn kidney has a limited capacity to excrete excess water and sodium. So overload of fluid or sodium in the 1st week of life  morbidities like PDA, NEC and BPD TERM 800 PRETERM 600
  4. 4. BODY COMPOSITION CHANGES IN BODY WATER SOLUTE DISTRIBUTION WATER LOSS NEUROENDOCRINE CONTROL
  5. 5. BODY COMPOSITION CHANGES IN BODY WATER
  6. 6. 94% of Body WT at 3RD MONTH OF GESTATION 78% at TERM ↑RENAL FUNCTION ATRIAL NATRIURETIC PEPTIDE TBW & ECW : Preterm > Term SGA > AGAPOST NATAL ECW CONTRACTION ECW ↓ ICW ↑ ICW > ECW by 3 months of life
  7. 7. CHANGES IN BODY WATER AND ELECTROLYTE COMPOSITION DURING INTRAUTERINE AND EARLY POSTNATAL LIFE Gestational Age (Weeks) Component 24 28 32 36 40 1 to 4Weeks After Term Birth Total body water (%) 86 84 82 80 78 74 Extracellular water (%) 59 56 52 48 44 41 Intracellular water (%) 27 28 30 32 34 33 Sodium (mEq/kg) 99 91 85 80 77 73 Potassium (mEq/kg) 40 41 40 41 41 42 Chloride (mEq/kg) 70 67 62 56 51 48
  8. 8. Changes in body water during gestation and infancy 3rd month
  9. 9. Distribution of body water in a term newborn infant
  10. 10. BODY COMPOSITION CHANGES IN BODY WATER SOLUTE DISTRIBUTION WATER LOSS NEUROENDOCRINE CONTROL
  11. 11. Ion distribution in the blood plasma, which represents extracellular fluid, and in the intracellular fluid compartment. ECF: Plasma – Non plasma (interstitial) = PROTEINS
  12. 12. BODY COMPOSITION CHANGES IN BODY WATER SOLUTE DISTRIBUTION WATER LOSS NEUROENDOCRINE CONTROL
  13. 13. WATER LOSS SENSIBLE INSENSIBLE Kidney GIT Skin 70% Respiratory Tract 30%
  14. 14. PHYSIOLOGICAL WEIGHT LOSS: Salt and Water Diuresis (48-72 hrs) Fluid Shift ICF  ECF Weight Loss ECF: Preterm > Term Weight Loss : Preterm (15%) > Term (10%)
  15. 15. INSENSIBLE WATER LOSS: Insensible Water Loss according to Birth Weight on Day 5 BIRTH WEIGHT IWL (ml/Kg/day) <1000 gm 60-80 1000-1500 gm 40-60 >1500 gm 20
  16. 16. FACTORS AFFECTING INSENSIBLE WATER LOSS IN NEWBORN INFANTS Factor Effect On Insensible Water Loss (Iwl) Level of matuqity Inveqsely pqopoqtional to biqth weight and gestational age Respiqatoqy distqess (hypeqpnea) Respiqatoqy IWL incqeases with qising minute ventilation when dqy aiq is being bqeathed Enviqonmental tempeqatuqe above neutqal theqmal zone Incqeased in pqopoqtion to incqement in tempeqatuqe Elevated body tempeqatuqe Incqeased by up to 300% Skin bqeakdown oq injuqy Incqeased by unceqtain magnitude Congenital skin defect (e.g.,gastqoschisis, omphalocele,
  17. 17. FACTORS AFFECTING INSENSIBLE WATER LOSS IN NEWBORN INFANTS Factor Effect On Insensible Water Loss (Iwl) High ambient oq inspiqed humidity Reduced by 30% when ambient vapoq pqessuqe Is incqeased by 200% Plastic heat shield Reduced by 30% to 70% Plastic blanket oq chambeq Reduced by 30% to 70% Semipeqmeable membqane Reduced by 50% Topical agents Reduced by 50%
  18. 18. INSENSIBLE WATER LOSS: PREVENTION > CURE (REPLACEMENT) IWL  PRETERM>TERM Reasons : Immaturity of Skin Barrier Respiratory Distress greater skin blood flow larger body water *ESSENTIAL FATTY ACID DEFICIENCY MEASURES : INCUBATOR HUMIDIFICATION SYSTEMS PLEXIGLASS HEAT SHIELDS THIN BARRIERS OF SARAN THIN PLASTIC BLANKETS SEMIPERMEABLE MEMBRANES WATER PROOF TOPICAL AGENTS
  19. 19. BODY COMPOSITION CHANGES IN BODY WATER SOLUTE DISTRIBUTION WATER LOSS NEUROENDOCRINE CONTROL
  20. 20. NEUROENDOCRINE CONTROL: Pituitary : ADH & ACTH Adrenal : Aldosterone activators : RAS, ACTH, Na + ,K+  but poor response of TUBULES Parathyroid : PTH (↑) vs  Ca2+ Thyroid : Calcitonin (↓) ANF : Na+ and H2O excretion  Postnatal Diuresis
  21. 21. PRINCIPLES OF THERAPY: Estimate Calculate Administer Monitor Replacement of Deficits Maintenance Replacement of ongoing losses
  22. 22. Estimate FLUID ELECTROLYTE ½ CATIONS(¼ SODIUM + ¼ POTASSIUM) ½ ANIONS Dehydration Isotonic Na+= 130-150 Hypertonic  Na+= >150 Hypotonic  Na+= <130 ***From clinical symptoms and signs E.g. 1.Severe acute diarrhea – isotonic 2.High IWL – hypernatremic 3.Inadequate salt loss replacement – hypotonic.
  23. 23. Calculate Replacement Maintenance Rapid correction Exception : Hypertonic Dehydration Na+ correction over 24 hrs K+ correction over 48-72 hrs. Ongoing losses Vomiting / Diarrhea/ RTA
  24. 24. DEFICIT – REPLACEMENT:  Dehydration: Moderate (10%) to Severe(15%) correction over 24hrs N/2 ½ in 8hrs + ½ in 16 hrs + Maintenance in 24 hrs (N/5 + 10% D @ 100ml/Kg/day)  Shock: Stat NS @ 10-20 ml/Kg in 1-2 hrs ↓ Correction  ½ in 8hrs + ½ in 16 hrs + Maintenance
  25. 25. Type of Dehydration Serum Sodium Concentration (mEq/L) Calculation of Total Solute Deficit (mOsm/kg)a Solute Deficit (mOsm/kg) Sodium Deficit (mEq/kg) b Isotonic (10%) 140 (0.7 ×280)–(0.6× 280) 28 14 Hypertonic (10%) 153 (0.7 ×280)–(0.6× 306) 12 6 Hypotonic (10%) 127 (0.7 ×280)–(0.6× 254) 44 22 a Total solute deficit = (TBWe × solutee - (TBWo × soluteo), where subscripts e and o indicate expected and observed, respectively. TBW e =0.7 L/kg; TBW o = 0.7 - 0.1 = 0.6 L/kg; solutee 140 × 2 = 280 mOsm/L, assuming total solute concentration in body water is twice the sodium concentration in serum; Solute o = observed serum sodium × 2. b Total solute deficit is assumed to be half sodium. Although the serum (and ECW) has lost this amount of sodium, only half this amount has been lost to the environment; the other half has been lost into the cells in exchange for potassium, which in turn has been lost from the body. In practice, therefore, only half the amount listed as “sodium deficit” should be replaced as sodium, and the other half should be given as potassium. TBW, total body water. ECW, extracellular water. TABLE 21-5 CALCULATION OF SODIUM DEFICIT
  26. 26. GUIDELINES FOR FLUID THERAPY: TERM Birth Weight Day 1 Day 2 to Day 7 Day 7 >1500 gm 60 (+15-20) 150 1000-1500 gm 80 (+10-15) 150 Day 1 : Solutes Excreted  15 mmol/Kg/day Acceptable Urine Osmolarity  300mmol/L  Minimum UOP required  50ml/Kg/day + IWL 20ml/Kg/day -------------------------------- Total 60-70ml/Kg/day 10% D @ 4-6mg/Kg/min Day 2 : Solute load increased + Fecal Losses + Growth Requirement  +15-20ml/Kg/day  + Na+, K+ after 48 hrs Day 7 : 150-160 ml/Kg/day DAILY FLUID REQUIREMENTS DURING 1ST WEEK OF LIFE (ml/Kg/day)
  27. 27. GUIDELINES FOR FLUID THERAPY: PRETERM Day 1 : UOP PRETERM = TERM but ACCORDING TO BODY WEIGHT THE LOSS IS PRETERM > TERM so fluid req. PT > TERM  80ml/Kg/day 10% D @ 4-6mg/Kg/min Day 2 :  +10-15ml/Kg/day  + Na+, K+ after 48 hrs Day 7 : 150-160 ml/Kg/day +Na+ supplementation @ 3-5 mEq/Kg upto 32-34 corrected weeks
  28. 28. 1.Birth weight : Term  1-3% per Day / 5-10% first week Preterm2-3% per Day / 15-20% first week Increased loss  fluid correction Decreased loss  fluid restriction 2.Clinical Examination : signs unreliable 10% dehydration-signs of dehydration 15% dehydration-shock 3.Serum Biochemistry : Na+ & plasma osmolarity Normal 135-145mmol/L Na+ HypernatremiaHyponatremia Weight: + - + - Disturbance : H2O excess Sodium Depletion Salt and H2O overload Dehydration Treatment: Fluid Restriction Sodium Replacement Salt andFluid Restriction Fluid correction (48 hrs) Monitor:
  29. 29. 4.Urine Parameters : Acceptable Range: Output  1-3ml/Kg/hr Specific Gravity  1.005-1.012 (by Dipstick or Refractometer) Osmolarity  100-400 mOsm/L (Freezing point osmometer) 5.Blood Gas : Poor perfusion and Shock  Metabolic Acidosis 6.Fractional Excretion of Na+: assess Renal Tubular Function limited value in Preterm (immaturity) 7.Serum Creatinine, BUN : assess Renal Function exponential fall in Serum Creat ( excretion of Maternal ) serial samples – better indicator  Renal failure Monitor:
  30. 30. LABORATORY GUIDELINES: IV FLUIDS: ELECTROLYTES: ↑ ↓ > 3% per day or > 20% cumulative Weight loss < 1% per day or < 5% cumulative > 145 mEq/L Serum Na+ < 130 mEq/L > 1.020/ > 400 mOsm/L Urine Specific Gravity/ Osmolarity < 1.005/ < 100 mOsm/L < 1 ml/Kg/hr UOP > 3ml/Kg/hr ELECTROLYTE RECOMMENDATION Na+ After 48 hrs @ 2-3 mEq/Kg/dayK+ Ca2+ For first 3 days in high risk conditions @ 4 ml (40 mg)/Kg/day Dextrose 10% 5% @ 4-6 mg/Kg/min If ≥1250 gm If <1250 gm EONH: -> Premature(<32wks) -> Preeclampsia ->IDM ->Perinatal Asphyxia (Apgar<4 @ 1 min) -> Maternal Hyper PTH ->IUGR ->Iatrogenic alkalosis
  31. 31. SPECIFIC CLINICAL CONDITIONS: 1.Extreme Prematurity : < 28 wks <1000 Kg - large IWL upto 1-2 wks till Stratum Corneum matures - ↓ requirement by ↓ing loss - 5% D ; electrolyte free on day 1 - Na+ K+ supplementation after 48 hrs 2. RDS : RDS hypoxia  ACIDOSIS  ↓ RENAL FUNCTION +VE PRESSURE VENTILATION  ↑ ALDOSTERONE & ADH H2O Retention  Symptomatic PDA. 3. Perinatal Asphyxia & Brain injury:  SIADH ↓ HYPONATREMIA => FLUID RESTRICTION (2/3RD Maintenance till Na+  normal) Renal Parenchymal Injury  ATNOliguric or Anuric RF ↓ FLUID(only replace IWL & Metabolic Requirement) @ 40ml/Kg or 400ml/m2 At RECOVERY --Na+ K+ losses –to be calculated n replaced 4. Diarrhea :  of FLUID DEFICIT over 24 hrs  Ongoing losses @ 6-8 hrs
  32. 32. FLUID RESTRICTION: Cochrane meta-analysis: Restricted fluid therapy Greater Wt loss + dehydration ↓ incidence of PDA, NEC & DEATH
  33. 33. Water (mL) Sodium (mEq) Potassium (mEq) Deficit 300 21 21 Maintenance 300 6 6 Ongoing losses 0 0 0 Total 600 27 27 Total/kg 200 9 9 a Water deficit: 0.10 × 3 kg. b Electrolyte deficits calculated as in Table 21-5 (14 mEq/kg × 3 kg divided between sodium and potassium). c Potassium deficit should be replaced slowly over 48 to 72 hours. d Maintenance water requirement assumed to be 100 mL/kg/day. TABLE 21-7 CALCULATION OF FLUID AND ELECTROLYTE INTAKE FOR A 3-KG INFANT WITH 10% ISOTONIC DEHYDRATION

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