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WHY THIS BORING TOPIC

WHY THIS BORING TOPIC. q Intake of Sick Newborn – at the mercy of neonatologist. q Small amount of fluid can make a big difference. q Fluid Overload - may lead to NEC, PDA, CLD. HOW WET ARE THE NEWBORN. q TBW - 0.7 L/kg in Newborn 0.6 L/kg at 1yr. Age q ECF 40% - Newborn

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WHY THIS BORING TOPIC

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  1. WHY THIS BORING TOPIC q Intake of Sick Newborn – at the mercy of neonatologist. q Small amount of fluid can make a big difference. q Fluid Overload - may lead to NEC, PDA, CLD.

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

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

  4. HOW MUCH FLUID TO BE GIVEN <1 kg 1-1.5 kg. >1.5 kg. 1st day 100 ml/kg. 80 ml/kg. 60 ml/kg. 7th day 190/ml/kg 170 ml/kg 150 ml/kg. q increase 15 ml/kg/day upto 6th day q Add  20 ml/kg/day for Phototherapy & Warmer. qAll calculation done on birth wt. till body wt. exceeds birth wt. q Fluid if prematures nursed in Plastic heat Sheild

  5. WHAT FLUID 1st 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% 25ml 25% D+ 75ml ISO – P  Na+ - 22.7 mEq / lit K+ - 18 mEq / lit Cl - 22 mEq / lit D - 10%

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

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

  8. KEY POINTS TO REMEMBER IN FLUID THERAPY Term – 1% Per day qAllow a wt. Loss Preterm – 2% Per day q 1st 48 hrs – no electrolyte required q Replace  Gastric fluid loss  ½ NS + KCL  Other body fluids  NS + KCL q Give fluid direction 8-12 hrly in sick neonates

  9. Premature 1.25 kg. day 1 give fluid direction q 10% Dextrose q 80 ml / day q 20 ml 6 hourly q 10% Dextrose 3.5ml / hr = 3 drops / min

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

  11. ELECTROLYTE REQUIREMENT • 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

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

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

  14. GLUCOSE REQUIREMENT qOptimum requirement 4-6 mg / kg / min q Conc. Used - 5%, 10%, 12.5% (max) q Glucose infuse – (mg / kg / min) = % Gx rate (ml / hr.) x 0.167 x wt. q Thumb rule – 3 ml / kg / hr of 10% D = 5mg / kg / min q Remain careful about glucose in – LBW IDM IUGR

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

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

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

  18. Peripheral lines: Indications & Purpose • Maintain fluid, electrolyte & acid-base balance in neonate • Provide IV medications. • Provide blood or blood components. • Provide peripheral parenteral nutrition. • N B: do not try > 2consecutive times by the same person !

  19. Preliminary steps

  20. Insertion of Line

  21. Monitoring & Discontinuation • Observe rate, patency ,air within the line. • Observe for local warmth, pain,leak redeness ,edema, blanching. • Flush with 2 ml N.Saline (with asepsis) if needed to check the line. • Indication : on order / leak / phlebitis / thrombosis / blanching (except with ionotrope infusion). • Stop fluid / asepsis / remove dressings / remove cannula / press until bleeding stops / dress with iodine. • Send cannula tip for culture if phlebitis.

  22. Umbilical venous line • Purpose : Central line for medication, exchange transfusion, pressure monitoring and fluid (rarely) • Policy : Should be done by a doctor only. • Emphasis : Tip in ductus/IVC, do not advance once secured, do not keep open, very careful about sepsis. • Equipment : 5Fr for < 3.5 kg; 8Fr for > 3.5kg.( It should have side holes at tip ), forceps, scalpel,probe, suture, drapes, asepsis utensils, tapes, ties etc. )

  23. UVC Procedure • Estimate length of the catheter(graph), assemble equipments • Universal asepsis. • Identify UV( patulous, single, bleeding, at 12 o’clock) / grasp cord with toothed forceps / remove clots from vein by iris forcep • Introduce fluid filled catheter with stop cock 2-3 cm inside vein / suck for blood / remove clot if no free flow of blood /remove, rotate & reinsert until free flow comes / advance to desired length • Fix UVC once free flow established with tapes. Radiology confirmation (D9-D10 or just above right diaphragm).

  24. Capillary Blood Sampling • Purpose : heel prick blood sampling • Emphasis : safe and effective / maxm. 2 pricks per heel (except sick newborn). • Policy : preferably doctors/ only trained nurse. • Indications : sugar / blood gas / Hct / sepsis screen / bilirubin / biochemistry. • Equipment: asepsis utensils, lancet, capillary tubes, gauze.

  25. Procedure of CBS • Ask sister to bundle the neonate. Chose the site (picture). Warm the area with dry warm cloth. • Universal asepsis. Perform lancet puncture in most medial or lateral aspect of plantar surface (avoid puncture on previous or previous weight bearing sites of the neonates). • Discard first drop of blood / hold the site downward / keep gentle continuous pressure /avoid ‘milking’ / Collect in capillary tube / • Stop bleeding by pressure / apply Iodine / label each tube / send with details quickly / document all details.

  26. Special situations

  27. 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 –30th day gained wt. 25 gm / day despite a fall of • Urine vol from 3 ml / kg / hr. 0.5 ml / kg / hr • qDiagnosis • q Management

  28. CASE…. - A 30 yrs Woman P2+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 18 59 - after 6 hrs. the baby dev. Seizure q What is the most likely cause of seizure? q How to prevent this?

  29. HYPONATREMIA qSerum Na+ <130 mEq / lit q Neurological Signs or Na+ <120 mEq / lit  treat promptly qWhat 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 q NaHco3 7.5% solution  0.9 mEq Na+ / ml (if 3% Nacl not available)

  30. HYPONATREMIA……. qHow 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. q Thumb rule - correct 1/3rd 8hr 1/3rd 16 hr 1/3rd 24 - 48 hr.

  31. Male baby of 7 days wt. 1.5 kgs., serum Na+ obs. 122 mEq. / lt. How to correct the hyponatremia ? q Deficit of Na+ = (135 – 122) x 1.5 x 0.6 = 11.7 mEq. q Maintenance Na+ = 3 x 1.5 x 2 (correction made in 48 hrs.) = 9 mEq. q Total requirements = 11.7 +9 = 20.7 mEq. = 21 mEq. q Fluid requirements for 48 hrs. = 1.5 x 150 x 2 = 450 ml. q 21 mEq Na+ in 450 ml. fluid = 50 mEq. Na+ in 1 lit. q Fluid required = 450 ml. N/3 Solution.

  32. HYPERNATREMIA q Serum Na> 150 mEq / lit q Excess free water loss than Na+ q Do not treat with Na+ free water q Fluid therapy -- 2/3 maintenance with N2 / N5 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.

  33. SIADH q Predisposing factors present Feature q wt. Gain with out oedema q hypotonic hyponatremia q Urine output q Urine osmolality > plasma osmolality Treat q Water restriction – 2/3 maintenance x 24 hrs q 3% Nacl if Na+ <120 mEq / lit or CNS sign q Frusemide  Urinary electrolyte free H2o excretion

  34. HYPOKALEMIA A Newborn 3kgs on 2nd day developed abdominal distension, NG tube inserted, on 3rd 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

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

  36. HYPERKALEMIA q Serum K+ > 6 mEq / lit q 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.

  37. HYPERKALEMIA…. • K+ > 7 mEq / lit - Co – gluconate 1- 2ml / kg over 5 min • - NaHCo3 1 – 2ml / kg slowly • - 2ml / kg of 10% D + 0.05 units / kg regular insulin followed by – infusion • - Kayexelate • - Salbatatnoe Nebalisation 4mcg / kg • 5. If above measure fails  • Peritoneal dialysis •  Exchange transfusion • ECG  Tall  T /  PR /  QRS

  38. Commercial electrolyte and dextrose stock sol.

  39. Composition of commercial I.V. fluid available

  40. HYPOCALCAEMIA Serum Calcium <7.0 mg / dl Ionised Cal <4.0 mg / dl Seizure Treatment of Hypocalcaemic Crisis apnoea Tetaxy 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

  41. HYPOCALCAEMIA ……… Refactory hypocalcaemia  think hypomagnesaemia  0.2ml of 50% mgso4 2 doses 12hr. Apart i/v or deep im Caution in Ca++ therapy q Rapid i/v infusion - dysrythmia / bradycardia q Extravasation of Ca++ Solution  S/C necrosis & Calcification

  42. Thank U

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