1. 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

2. 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.

3. HOW WET ARE THE NEWBORN  TBW - 0.7 L/kg in Newborn 0.6 L/kg at 1yr. Age  ECF40% - Newborn 20% - Older Children

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

5. 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

6. 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 cvD - 10%

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

8. 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.

9. 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

10. 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

11. 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.

12. ELECTROLYTE REQUIREMENT A.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

13. ELECTROLYTE REQUIREMENT…. B.POTASIUM : Add -from day 3 can wait till serum K+ < 4 in small prematures Require -2 - 3 mEq / kg / day

14. 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

15. 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

16. 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

17. 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

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

19. 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 + 133 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. 1040.  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

20. 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 1 8 5 9 - after 6 hrs. the baby dev. Seizure  What is the most likely cause of seizure?  How to prevent this?

21. 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)

22. 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 24 - 48 hr.

23. 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 = 11.7 +9 = 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.

24. 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.

25. 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

26. 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 = (3.5 - 2.1) x 3 3 = 1.4 mEq

27. 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

28. 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.

29. 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 + 0.05 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

30. SolutionConcentrationAvailable fromEquivalents Soda bicarb solution 7.5%10 ml ampoule1 ml = 1 mEq of HCO 3 + 1 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.

31. Dextr.NaKClLactatCamOsm/L G/L IsotonicNS154 308 RL1315111292270 ½ isotonic½ NS77 154 Electrolyte free solution 5%50278 10%100556 Dextrose, electrolyte solution 5% DNS50154 585 D5 ½ NS5077 415 D5 0.33% NaCl 5057 381 D5 0.2% NaCl 5034 347 Ped. Maint.Isolyte P50252022368 Composition of commercial i.v. fluid available

32. 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 + 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

33. 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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