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WORKSHOP on NEONATAL FLUID ELECTROLYTE THERAPY Presented By : Dr. Swapan Chakraborty Dr. Subhasis Roy Dr. Subrata Chakraborty Dr. Amit Roy Dr. A. Moulik Dr. Atul Gupta

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WHY THIS BORING TOPIC skin Intake= output renal fecal sound knowledge of neonatologist Small amount of fluid can make a big difference. Fluid Overload - may lead to NEC, PDA, CLD.

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HOW WET ARE THE NEWBORN TBW L/kg in Newborn 0.6 L/kg at 1yr. Age ECF40% - Newborn 20% - Older Children

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

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HOW MUCH FLUID TO BE GIVEN 1.5 kg. 1 st day 100 ml/kg.80 ml/kg. 60 ml/kg. 7 th day 190/ml/kg170 ml/kg 150 ml/kg. increase 15 ml/kg/day upto 6 th day Add 20 ml/kg/day for Phototherapy & Warmer. All calculation done on birth wt. till body wt. exceeds birth wt. Fluid if prematures nursed in Plastic heat Sheild

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

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

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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.

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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 Replace Gastric fluid loss ½ NS + KCL Other body fluids NS + KCL Give fluid direction 8-12 hrly in sick neonates

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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

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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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ELECTROLYTE REQUIREMENT A.SODIUM : Add -from day In VLBW add when lost 6% wt. Require -Term & LBW mEq / kg / day ELBW mEq / kg / day

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ELECTROLYTE REQUIREMENT…. B.POTASIUM : Add -from day 3 can wait till serum K+ < 4 in small prematures Require mEq / kg / day

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

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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 x wt. Thumb rule – 3 ml / kg / hr of 10% D = 5mg / kg / min Remain careful about glucose in – LBW IDM IUGR

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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 Euglycaemia - 75 – 100 mg / dl Normonatremia mEq / lit Normokalemia - 4 – 5 mEq / lit

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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

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MONITORING FLUID ELECTROLYTE THERAPY …... Check Daily - if possible Serum Na + Serum K + Blood Urea Serum Creatinine

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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 mEq / lit, K + 4mEq / lit urine output 2-4 ml / kg / hr Day 30 Na + <100 mEq / lit, serum osmola 204 mosm / lit Urine Sp gr From 28 –30 th day gained wt. 25 gm / day despite a fall of Urine vol from 3 ml / kg / hr. 0.5 ml / kg / hr Diagnosis Management

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CASE…. - A 30 yrs Woman P 2 +o taken to labour room - In last 1 hr of labour woman drunk 3L water + received 5% D i/v - Delivered male baby 3kg, apgar after 6 hrs. the baby dev. Seizure What is the most likely cause of seizure? How to prevent this?

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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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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 - correct1/3 rd 8hr 1/3 rd 16 hr 1/3 rd 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 ? Deficit of Na+ = (135 – 122) x 1.5 x 0.6 = 11.7 mEq. Maintenance Na+ = 3 x 1.5 x 2 ( correction made in 48 hrs.) = 9 mEq. Total requirements = = 20.7 mEq. = 21 mEq. Fluid requirements for 48 hrs. = 1.5 x 150 x 2 = 450 ml. 21 mEq Na+ in 450 ml. fluid = 50 mEq. Na+ in 1 lit. Fluid required = 450 ml. N/3 Solution.

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HYPERNATREMIA Serum Na> 150 mEq / lit Excess free water loss than Na + 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 >10 mEq / lit / day. -- May require 3% NaCl if over correction leads to CNS signs.

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SIADH Predisposing factors present Feature wt. Gain with out oedema hypotonic hyponatremia Urine output Urine osmolality > plasma osmolality Treat Water restriction – 2/3 maintenance x 24 hrs 3% Nacl if Na + <120 mEq / lit or CNS sign Frusemide Urinary electrolyte free H 2 o excretion

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HYPOKALEMIA A Newborn 3kgs on 2 nd day developed abdominal distension, NG tube inserted, on 3 rd day Serum K + observed was 2.1 mEq / lit. How to correct. K + deficit = (Req K + - obs K + ) x body wt. 3 = ( ) x 3 3 = 1.4 mEq

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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 – mEq / lit Signs of hypokalenia in newborn – ileus Obtundation QT / ST depression

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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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HYPERKALEMIA…. 4.K+ > 7 mEq / lit - Ca – gluconate 1- 2ml / kg over 5 min - NaHCo 3 1 – 2ml / kg slowly - 2ml / kg of 10% D units / kg regular insulin followed by – infusion - Kayexelate - Salbutamol Nebulisation 4mcg / kg 5.If above measure fails Peritoneal dialysis Exchange transfusion ECG Tall - T / PR / QRS

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SolutionConcentrationAvailable fromEquivalents Soda bicarb solution 7.5%10 ml ampoule1 ml = 1 mEq of HCO mEq of Na Potassium Chloride15% w/v10 ml ampoule1 ml = 2 mEq of K Calcium gluconate10% w/v10 ml ampoule1 ml = 9.3 mg of Cal. Magnesium sulphate 50% and 25%2 ml ampouleIf 25% Mg 4.15 mOsm/dL Sodium Chloride3%10 ml ampoule 50 ml bottle 1 ml = 0.5 mEq of Na 25% Dextrose25 w/v 25 G/100 ml10 ml ampoule and 25 ml ampoule 50% Dextrose50 w/v 50 G/100 ml25 ml ampoule Commercial electrolyte and dextrose stock sol.

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Dextr.NaKClLactatCamOsm/L G/L IsotonicNS RL ½ isotonic½ NS Electrolyte free solution 5% % Dextrose, electrolyte solution 5% DNS D5 ½ NS D5 0.33% NaCl D5 0.2% NaCl Ped. Maint.Isolyte P Composition of commercial i.v. fluid available

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HYPOCALCAEMIA Serum calcium <7.0 mg / dl ionised cal <4.0 mg / dl Seizure Treatment of Hypocalcaemic Crisis apnoea Tetany 1 – 2ml Ca-glu. / kg % 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 … Refractory hypocalcaemia think hypomagnesaemia 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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