This document discusses fluid and electrolyte balance in newborns. Key points include: 1) Total body water and extracellular fluid decrease as gestational age increases at birth, while intracellular fluid increases. 2) Term infants lose 5-10% of their body weight in the first few days of life due to reduction in extracellular fluid. 3) Preterm infants under 35 weeks gestation display negative sodium balance and hyponatremia in the first 2-3 weeks of life due to high renal sodium losses. 4) Fluid requirements vary based on weight, with very low birth weight infants needing higher amounts to offset insensible water losses. Close monitoring of fluid balance is important in

1. Fluid and electrolyte imbalance MONIKA NANDA 20/2/2009

4. HOW WET ARE THE NEWBORN  TBW - 0.7 L/kg in Newborn 0.6 L/kg at 1yr. Age  ECF 40% - Newborn 20% - Older Children

12. WHO REQUIRE FLUID  Infant < 30 wks. & <1250 gm.  Sick Term Newborns - Severe birth asphyxia - Apnoea - RDS - Sepsis - Seizure

13. HOW MUCH FLUID TO BE GIVEN <1 kg 1-1.5 kg. >1.5 kg. 1 st day 100 ml/kg. 80 ml/kg. 60 ml/kg. 7 th day 190/ml/kg 170 ml/kg 150 ml/kg.  increase 15 ml/kg/day upto 6 th day  Add  20 ml/kg/day for Phototherapy & Warmer.

15. WHAT FLUID 1 st 48 hrs. <1 kg - 5% Dextrose 1-1.5 kg. - 10% Dextrose >1.5 kg. - 10% Dextrose After that  ISO – P  Na + - 20 mEq / lit K + - 20 mEq / lit Cl - 25 mEq / lit D - 5% OR 25ml 25% D + 75ml ISO – P  Na + - 22.7 mEq / lit K + - 18 mEq / lit Cl - 22 mEq / lit D - 10%

16. LESS FLUID Birth asphyxia Meningitis Pneumothorax IVH PDA CLD 2/3 of Maintenance

18. EXTRA FLUID  NEC & other condition with loss in 3 rd space  May require upto 200ml / kg – repeated 10ml / kg RL/NS bolus.  ELBW / VLBW neonates – Due to high IWL.

19. KEY POINTS TO REMEMBER IN FLUID THERAPY Term – 1% Per day  Allow a wt. Loss Preterm – 2% Per day  1 st 48 hrs – no electrolyte required

21. Premature 1.25 kg. day 1 give fluid direction  10% Dextrose  100 ml / day  25 ml 6 hourly  10% Dextrose 4 ml / hr = 4drops / min

22. A 3 kgs., term sick newborn on 4 th day under radiant warmer & phototherapy, calculate fluid requirement  ISO – P  315 ml + 60 ml + 60 ml = 435 ml  108 ml / 6 hrs.  18 ml / hr. = 18 drops / min.

26. ELECTROLYTE REQUIREMENT.... C. CALCIUM :  Give to IDM Preterm Birth asphyxia <1500 gm.  Add from day 1.  36-72 mEq / kg / day or 4- 8 ml / kg / day of 10% Cal. gluconate

27. Commercial electrolyte and dextrose stock sol. 25 ml ampoule 50 w/v 50 G/100 ml 50% Dextrose 10 ml ampoule and 25 ml ampoule 25 w/v 25 G/100 ml 25% Dextrose 1 ml = 0.5 mEq of Na 10 ml ampoule 50 ml bottle 3% Sodium Chloride If 25% Mg 4.15 mOsm/dL 2 ml ampoule 50% and 25% Magnesium sulphate 1 ml = 9.3 mg of Cal. 10 ml ampoule 10% w/v Calcium gluconate 1 ml = 2 mEq of K 10 ml ampoule 15% w/v Potassium Chloride 1 ml = 1 mEq of HCO 3 + 1 mEq of Na 10 ml ampoule 7.5% Soda bicarb solution Equivalents Available from Concentration Solution

28. Composition of commercial i.v. fluid available 368 22 20 25 50 Isolyte P Ped. Maint. 347 34 34 50 D5 0.2% NaCl 381 57 57 50 D5 0.33% NaCl 415 77 77 50 D5 ½ NS 585 154 154 50 5% DNS Dextrose, electrolyte solution 556 100 10% 278 50 5% Electrolyte free solution 154 77 77 ½ NS ½ isotonic 270 2 29 111 5 131 RL 308 154 154 NS Isotonic G/L mOsm/L Ca Lactat Cl K Na Dextr.

29. GOALS OF FLUID ELECTROLYTE THERAPY  Urine output 1 – 3 ml/kg/hr.  Allow a weight loss 1 – 2% / day in 1 st wk. (weigh the splint before putting i/v line)  Absence of Edema / Dehydration / Hepatomegaly  Urine Sp. gravity 1005 - 1015  Euglycaemia - 75 – 100 mg / dl  Normonatremia - 135 - 145 mEq / lit  Normokalemia - 4 – 5 mEq / lit

31. MONITORING FLUID ELECTROLYTE THERAPY Check Daily - Definitely  Wt. - loss > 3% - dehydration <1% over dehydration  Urine output <1 ml / kg / hr – dehydration or SIADH (Hourly) >4 ml / kg / hr. – overhydration / dieresis Napkin weight technique Collect in syringe from cotton  Urine specific gravity >1015 fluid deficit (each sample if possible) <1005 fluid overload  Blood Glucose  Clinical Signs

33. Physical Signs of Dehydration

37. CALCULATION-

39. Estimated water nd elec. Deficit in dehydration 4-10 2-5 2-5 120-180 hypertonic 20-28 10-14 10-14 50-100 hypotonic 16-20 8-10 8-10 100-150 isotonic Cl /hco3(meq/kg) K(meq/kg) Na(meq/kg.) Water(ml/kg)

40. HYPONATREMIA  Serum Na + <130 mEq / lit  Neurological Signs or Na + <120 mEq / lit  treat promptly  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  NaHco 3 7.5% solution  0.9 mEq Na + / ml (if 3% Nacl not available)

42. HYPONATREMIA…….  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.  Thumb rule - correct 1/3 rd 8hr 1/3 rd 16 hr 1/3 rd 24 - 48 hr.

44. HYPERNATREMIA  Serum Na> 150 mEq / lit  Excess free water loss than Na + (mc in ELBW infants)  Do not treat with Na + free water  Fluid therapy -- 2/3 maintenance with N 2 / N 5 sol. + 5% D. -- correct Na + over 24 – 48 hrs. Do not drop >1 mEq / kg / hour. -- May require 3% NaCl if over correction leads to CNS signs.

45. POTASSIUM 2 meq/kg/day The total body potassium deficit cannot be calculated from the serum potassium. l g of KCl contains 13.4 mEq K and 13.4 mEq Cl. 1ml KCl = 2 Meq The MAXIMUM safe rate of K infusion IV = 0.3 mEq/kg/hour (beware of K concentrations over 4 g/litre in IV fluid). Eg: For an 8 kg child with hypokalaemia, with IV fluid at 25 ml/hour: 8 x 0.3 = 2.4 mEq K MAXIMUM in 25 ml 2.4 mEq in 25 ml = 2.4 x 1000/25 or 96 mEq/l. 96 mEq K = 96/13.4 or 7g KCl per litre.= 48ml = max 4 ampules per pint To be safe, add only half this amount (3.5 g) to each litre.

48. HYPOKALEMIA …    Max K + i/v without ECG - monitoring – 40 mEq / lit = 2ml 1.5ml KCL / 100ml of Fluid.    Max K + i/v with ECG – monitoring – 60 - 80 mEq / lit    Signs of hypokalenia in newborn – ileus Obtundation  QT / ST depression

50. HYPERKALEMIA  Serum K + > 6 mEq / lit   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.

53. HYPOCALCAEMIA Serum calcium <7.0 mg / dl ionised cal <4.0 mg / dl (1mmol/L) Seizure Treatment of Hypocalcaemic Crisis apnoea Tetany 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

54. HYPOCALCAEMIA … Refractory hypocalcaemia  think hypomagnesaemia(0.8 mg/dl)  0.2ml of 50% mgso 4 2 doses 12hr. Apart i/v or deep im Caution in Ca ++ therapy  Rapid i/v infusion - dysrythmia / bradycardia  Extravasation of Ca ++ Solution  S/C necrosis & Calcification

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