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
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
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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.
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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
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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
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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.
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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
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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
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)
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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.
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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.
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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
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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.
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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