fluid and electrolyte therapy hemant new.ppt
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luid and electrolyte therapy hemant new.pptTRANSCRIPT
Dr. Hemant Parakh.MD, DM(neonatology).Dr. Hemant Parakh.MD, DM(neonatology).
FLUID & ELECTROLYTE MANAGEMENT IN NEONATES
FLUID & ELECTROLYTE MANAGEMENT IN NEONATES
Fluid & Electrolyte Management in NeonatesFluid & Electrolyte Management in Neonates
Critical Aspect of
Care of High Risk Infants High frequency of parenteral fluid
administration
Variability in factors affecting the quantity &
composition of fluid requirement
Limitation in renal adjustment
Serious morbidities resulting from fluid &
electrolyte imbalance
0 3 6 9 // 0 3 6 9 0
20
40
60
80
100
60%
45%
26%
30%
42%36%32%
26%
Age in months
N e w- B o r n
TBW
ECW
ICW
TBW……ECF…..ICF
Perinatal Changes in TBW
Isotonic contraction of ECF -
physiological transition
Weight loss in 1st week of life
Term - 5 to 10%
Preterm 10 to 20%Can lead to imbalances in sodium and water homeostasis
Perinatal Changes in TBW
Isotonic contraction of ECF -
physiological transition
Weight loss in 1st week of life
Term - 5 to 10%
Preterm 10 to 20%Can lead to imbalances in sodium and water homeostasis
Fluid & Electrolyte Management in NeonatesFluid & Electrolyte Management in Neonates
Sodium balance in the newborn Sodium balance in the newborn
Renal sodium losses are inversely proportional to gestational age
Term infants have Fractional excretion of sodium = 1% with transient increases on day 2 and
At 28 weeks- Fractional excretion of Sodium = 5% to 6%
Preterm infants <35wks display negative sodium balance and hyponatremia during first 2-3 wks of life
Renal sodium losses are inversely proportional to gestational age
Term infants have Fractional excretion of sodium = 1% with transient increases on day 2 and
At 28 weeks- Fractional excretion of Sodium = 5% to 6%
Preterm infants <35wks display negative sodium balance and hyponatremia during first 2-3 wks of life
Sodium balance in the newborn Sodium balance in the newborn
Preterm infants may need 4-5mEq/kg of sodium per day to offset high renal losses
Increased urinary sodium losses hypoxia respiratory distress hyperbilirubinemia ATN polycythemia diuretics.
Preterm infants may need 4-5mEq/kg of sodium per day to offset high renal losses
Increased urinary sodium losses hypoxia respiratory distress hyperbilirubinemia ATN polycythemia diuretics.
Sodium balance in the newborn Sodium balance in the newborn
Pharmacologic agents like dopamine, increase urinary sodium losses
Fetal and postnatal kidneys exhibit diminished responsiveness to aldosterone compared to adult kidneys
Pharmacologic agents like dopamine, increase urinary sodium losses
Fetal and postnatal kidneys exhibit diminished responsiveness to aldosterone compared to adult kidneys
Water balance in the newborn Water balance in the newborn
Primarily controlled by ADH which enables water to be reabsorbed by the distal nephron collecting duct
Stimulation of ADH occurs when blood volume is diminished or when serum osmolality increases above 285mOsm/kg
Intravascular volume has a greater influence on ADH secretion than serum osmolality
Primarily controlled by ADH which enables water to be reabsorbed by the distal nephron collecting duct
Stimulation of ADH occurs when blood volume is diminished or when serum osmolality increases above 285mOsm/kg
Intravascular volume has a greater influence on ADH secretion than serum osmolality
Renal Function Status Related to F&E Management
Deficient concentrating & diluting capacity. Concentration Dilution
mosm / kg mosm / kg
Adults 1200 - 1500 50
Term 800 50
Preterm 600 70 Risk of dehydration Risk of volume overload
with fluid restriction with increased fluid intake
Renal Function Status Related to F&E Management
Deficient concentrating & diluting capacity. Concentration Dilution
mosm / kg mosm / kg
Adults 1200 - 1500 50
Term 800 50
Preterm 600 70 Risk of dehydration Risk of volume overload
with fluid restriction with increased fluid intake
Fluid & Electrolyte Management in NeonatesFluid & Electrolyte Management in Neonates
Limited capacity to concentrate or dilute urine, neither excrete and conserve Na.
Esp.. Preterm babies limited tubular capacity to reabsorb Na.
Limited capacity to acidify urine GFR gestational age
Limited capacity to concentrate or dilute urine, neither excrete and conserve Na.
Esp.. Preterm babies limited tubular capacity to reabsorb Na.
Limited capacity to acidify urine GFR gestational age
Adult Term Preterm
Concen. capacity
Diluting capacity
1500 800 600
50
mOsmol/kg
Renal Prematurity cont…
Limited capacity….. CONCENTRATE and dilute urine
Risk to develop….. Hypernitremia (Dehydration)Hyponitremia (Over-hydration)Hyperkalemia Acidosis
Risk to develop….. Hypernitremia (Dehydration)Hyponitremia (Over-hydration)Hyperkalemia Acidosis
Failure to concentrate and dilute…..
Babies < 30-32 wks gestn may continue
to pass large amounts of dilute urine despite dehydration becoz of renal immaturity. Hence urine output and specific gravity maybe an unreliable indicator of fluid status in these babies.
Babies < 30-32 wks gestn may continue
to pass large amounts of dilute urine despite dehydration becoz of renal immaturity. Hence urine output and specific gravity maybe an unreliable indicator of fluid status in these babies.
Principles of F&E Therapy
3 components of F&E requirements Maintenance fluid Replacement of losses Replacement of current loss
More important in infant with diarrhea and dehydration, chest tube drainage, surgical wound, osmotic diuresis
Principles of F&E Therapy
3 components of F&E requirements Maintenance fluid Replacement of losses Replacement of current loss
More important in infant with diarrhea and dehydration, chest tube drainage, surgical wound, osmotic diuresis
Fluid & Electrolyte Management in NeonatesFluid & Electrolyte Management in Neonates
Maintenance Fluid To replace physiologic losses
Insensible water loss (IWL) Renal water loss Stool water loss Sweat loss - Negligible in
newborns
Maintenance Fluid To replace physiologic losses
Insensible water loss (IWL) Renal water loss Stool water loss Sweat loss - Negligible in
newborns
Fluid & Electrolyte Management in NeonatesFluid & Electrolyte Management in Neonates
Insensible Water Loss IWL is water that evaporates in
an invisible manner via skin
(2/3) or respiratory tract (1/3)
Most variable component of
fluid calculation
Various factors influence IWL
Insensible Water Loss IWL is water that evaporates in
an invisible manner via skin
(2/3) or respiratory tract (1/3)
Most variable component of
fluid calculation
Various factors influence IWL
Fluid & Electrolyte Management in NeonatesFluid & Electrolyte Management in Neonates
Average IWL of Premature Infant (ml/kg/d)
Age (d) Birth wt (Kg)
0.75-1.0 1.0-1.5 1.5-2.0 0 - 7 65 55 - 40 20 - 15 7 - 14 60 50 - 40 30 - 20
Higher surface area/body wt ratio Immature skin Increased skin vascularity
Average IWL of Premature Infant (ml/kg/d)
Age (d) Birth wt (Kg)
0.75-1.0 1.0-1.5 1.5-2.0 0 - 7 65 55 - 40 20 - 15 7 - 14 60 50 - 40 30 - 20
Higher surface area/body wt ratio Immature skin Increased skin vascularity
Fluid & Electrolyte Management in NeonatesFluid & Electrolyte Management in Neonates
Renal Water Loss Status of renal function
Renal solute load
Age Solute Water load req.for excretion mosm / kg / d ml / kg / d
< 1wk 5 20
> 2wk 15 - 20 60 - 80
Renal Water Loss Status of renal function
Renal solute load
Age Solute Water load req.for excretion mosm / kg / d ml / kg / d
< 1wk 5 20
> 2wk 15 - 20 60 - 80
Fluid & Electrolyte Management in NeonatesFluid & Electrolyte Management in Neonates
Water for Growth Water required for formation
of new tissue in growing infant.
20 to 25 ml / kg / day as infant grows at rate of 25 to 30 g / kg / d & the new tissue contains 70% water.
Water for Growth Water required for formation
of new tissue in growing infant.
20 to 25 ml / kg / day as infant grows at rate of 25 to 30 g / kg / d & the new tissue contains 70% water.
Fluid & Electrolyte Management in NeonatesFluid & Electrolyte Management in Neonates
Replacement of Deficit & Replacement of Current Losses
Measure the volume & composition of abnormal fluid loss & replace volume per volume & mole per mole basis
Replacement of Deficit & Replacement of Current Losses
Measure the volume & composition of abnormal fluid loss & replace volume per volume & mole per mole basis
Fluid & Electrolyte Management in NeonatesFluid & Electrolyte Management in Neonates
Electrolytes
0 0.5 0.75 1.0 1.5 1.75 2 .0 2.5 3
Wt in Kg
8
7
6
5
4
3
2
1
Glucose GM%
2 mEq / 100 mlmE
q /
100
ml
4-5 m Eq/kg
<32 wks
Na
3 mEq/kg
10 gms / 100 ml5 gms/100ml
Electrolyte Requirement Maintenance Na & Cl after first 48
hours
Maintenance K after normal renal
function is ensured Requirement < 1wk 1 - 2 meq / kg / d
> 1wk 2 - 3 meq / kg / d
Maintenance Ca from day 1.
Electrolyte Requirement Maintenance Na & Cl after first 48
hours
Maintenance K after normal renal
function is ensured Requirement < 1wk 1 - 2 meq / kg / d
> 1wk 2 - 3 meq / kg / d
Maintenance Ca from day 1.
Fluid & Electrolyte Management in NeonatesFluid & Electrolyte Management in Neonates
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
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
POTASIUM : Add - from day 3 can wait till serum K+ < 4 in small prematures Require - 2 - 3 mEq / kg / day
POTASIUM : Add - from day 3 can wait till serum K+ < 4 in small prematures Require - 2 - 3 mEq / kg / day
Common Parenteral Fluids…………….Common Parenteral Fluids…………….
SolutionGlucose
(g/L)Na+ K+ Cl- Lactate mOsm/l
10% Dextrose 100 0 0 0 0 500
5% Dextrose (D5W) 50 0 0 0 0 250
0.9% Normal Saline (NS)
0 154 0 154 0 308
D5 0.9NS 50 154 0 154 0 560
D5½NS ( 0.45%) 50 77 0 77 0 406
D5¼NS(0.2%) 50 38 38 0 320
Isolyte-P 50 25 20 22 0 368Isolyte-P 50 25 20 22 0 368
↑ Osmolality + ↑ Na
↓ Osmolality + ↓ Na
Maintenance Fluid Requirements
Initial fluid therapy
Birth Dextrose Fluid ml / kg / d wt (kg) conc. < 24 24-48 >48
< 1.0 5 % 100 120 140 1.0 - 1.5 10% 80 100 120 > 1.5 10% 60 80 120 Guidelines to be used as starting point Fluid requirement to be revised as per monitoring data
Maintenance Fluid Requirements
Initial fluid therapy
Birth Dextrose Fluid ml / kg / d wt (kg) conc. < 24 24-48 >48
< 1.0 5 % 100 120 140 1.0 - 1.5 10% 80 100 120 > 1.5 10% 60 80 120 Guidelines to be used as starting point Fluid requirement to be revised as per monitoring data
Fluid & Electrolyte Management in NeonatesFluid & Electrolyte Management in Neonates
Increment…15 -20 ml /kg/day
Start….1st day……2.5-3.5 ml / kg / hr Add….0.5 ml to 1ml / kg /day
Wkend…..5-6 ml / kg / hr
Start….1st day……2.5-3.5 ml / kg / hr Add….0.5 ml to 1ml / kg /day
Wkend…..5-6 ml / kg / hr
Higher wt, Term …..lower requirementLower wt, Preterm ….. Higher requirement
Lorenz JM. Fluid and electrolyte therapy in the newborn infant. In: Burg FD, Polin RA, Ingelfinger JR, Gershon A, eds.Current Pediatric Therapy 17. Philadelphia, Pa: WB Saunders; 2002.
GLUCOSE REQUIREMENT 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
Glucose homeostasisStep 1 : Calculation of GIR
GIR (mg / kg / min)
= Fluid rate (... /kg / day) X 0.07
Eg. If rate of fluid is 100 ml / kg /d of 10% D
GIR = 100 X 0.07 = 7 mg / kg / min
Step 2 : Increasing GIR by 1 mg / kg / min
Add 2 ml / kg of 25% D to each 8 hr drip
Eg. from 7mg / kg / min GIR will increase to 8
mg / kg / min
Glucose homeostasisStep 1 : Calculation of GIR
GIR (mg / kg / min)
= Fluid rate (... /kg / day) X 0.07
Eg. If rate of fluid is 100 ml / kg /d of 10% D
GIR = 100 X 0.07 = 7 mg / kg / min
Step 2 : Increasing GIR by 1 mg / kg / min
Add 2 ml / kg of 25% D to each 8 hr drip
Eg. from 7mg / kg / min GIR will increase to 8
mg / kg / min
Fluid & Electrolyte Management in NeonatesFluid & Electrolyte Management in Neonates
Markers for Appropriate Fluid & Electrolyte Balance
U.O. 1 - 3 ml / kg / hr Wt loss - Term 5% Preterm 15% Urine specific gravity
1.008 to 1.012 Normal S.electrolytes Postnatal growth chart
Markers for Appropriate Fluid & Electrolyte Balance
U.O. 1 - 3 ml / kg / hr Wt loss - Term 5% Preterm 15% Urine specific gravity
1.008 to 1.012 Normal S.electrolytes Postnatal growth chart
Fluid & Electrolyte Management in NeonatesFluid & Electrolyte Management in Neonates
Postnatal growth Chart
Weight changes during first 50 days of life
Postnatal growth Chart
Weight changes during first 50 days of life
Fluid & Electrolyte Management in NeonatesFluid & Electrolyte Management in Neonates
Perinatal Asphyxia Oliguria / anuria due to SIADH or ATN
Restrict fluid intake during the period of reduced UO to avoid fluid overload. Restore fluid intake to normal level when UO is normal (D3). Avoid K during oliguric phase. Give crystalloid 10 ml / kg ( if cause of anuria is unclear) Administer low dose dopamine and lasix if required
Perinatal Asphyxia Oliguria / anuria due to SIADH or ATN
Restrict fluid intake during the period of reduced UO to avoid fluid overload. Restore fluid intake to normal level when UO is normal (D3). Avoid K during oliguric phase. Give crystalloid 10 ml / kg ( if cause of anuria is unclear) Administer low dose dopamine and lasix if required
Fluid & Electrolyte Management in NeonatesFluid & Electrolyte Management in Neonates
RDS Prediuretic phase (Stabilization phase)
Fluid restriction
Treat shock
Prevent hypoglycemia
Diuretic phase (Restriction maintenance phase)
Continue 2/3 restriction
Prevent dehydration
Postdiuretic phase (Liberalization phase)
Give full maintenance
RDS Prediuretic phase (Stabilization phase)
Fluid restriction
Treat shock
Prevent hypoglycemia
Diuretic phase (Restriction maintenance phase)
Continue 2/3 restriction
Prevent dehydration
Postdiuretic phase (Liberalization phase)
Give full maintenance
Fluid & Electrolyte Management in NeonatesFluid & Electrolyte Management in Neonates
PDA
Restrict fluids to 2/3 the
maintenance requirement
PDA
Restrict fluids to 2/3 the
maintenance requirement
Fluid & Electrolyte Management in NeonatesFluid & Electrolyte Management in Neonates
Diarrhea & Dehydration Dehydration of acute onset and short duration requires
more rapid correction Principles of fluid therapy similar to older infants &
children Fluid deficit volume judgement from acute weight
changes & degree of dehydration (More difficult to assess in preterms ) Replacement
50% water deficit - 1st 8 hours 50% water deficit - next 16 hoursNa deficit - 24 hoursK deficit - 48 - 72 hours
Diarrhea & Dehydration Dehydration of acute onset and short duration requires
more rapid correction Principles of fluid therapy similar to older infants &
children Fluid deficit volume judgement from acute weight
changes & degree of dehydration (More difficult to assess in preterms ) Replacement
50% water deficit - 1st 8 hours 50% water deficit - next 16 hoursNa deficit - 24 hoursK deficit - 48 - 72 hours
Fluid & Electrolyte Management in NeonatesFluid & Electrolyte Management in Neonates
Sick & Critically Ill Neonates Provide fluid & electrolyte replacement as per state of hydration & circulatory status Third space losses difficult to quantify & replace. No contribution to fluid & circulatory dynamics
Sick & Critically Ill Neonates Provide fluid & electrolyte replacement as per state of hydration & circulatory status Third space losses difficult to quantify & replace. No contribution to fluid & circulatory dynamics
Fluid & Electrolyte Management in NeonatesFluid & Electrolyte Management in Neonates
NO COOK-BOOK
APPROACH
There has been a lot of interest in the amount of fluid therapy and outcome of preterm neonates in terms of mortality and morbidity. The Cochrane meta-analysis on this topic could identify four eligible studies. Their findings state that, although restricted fluid therapy may lead to greater weight loss and dehydration, it is associated with a decreased incidence of death, PDA and NEC. There also seems to be a beneficial effect of restricted fluid therapy on the incidence of BPD.
The volume of fluids used in the restricted groups differs from the above-described fluid therapy by 20-50 ml/kg/day in the initial 3-4 days. Based on their meta-analysis, the investigators had concluded that fluid therapy needs to be balanced enough to meet the normal physiological needs without allowing significant dehydration.
Bell EF, Acarrgui MJ. Restricted versus liberal water intake for preventing morbidity and mortality in preterm infants. Cochrane Database Syst Rev 2000,(2):CD000503
Maintenance Fluid 1st day….2.5-3.5ml/kg/hr. Volume 5-6ml/kg/hr by wkend. Electrolytes after 48 hrs. Add K after pee Frequent clinical/ Lab monitoring…essential. “No cook book approach” Consideration of Restrictive strategy.
Maintenance Fluid 1st day….2.5-3.5ml/kg/hr. Volume 5-6ml/kg/hr by wkend. Electrolytes after 48 hrs. Add K after pee Frequent clinical/ Lab monitoring…essential. “No cook book approach” Consideration of Restrictive strategy.
Preterm…Abnormal Facies 4th G mother , vth bad obstetric, h/o…3 abortions, H/o PolyhydramniosH/o BA…..mild RDS…recovered…Persistantly Dehydrated (s/o volume depleted..↓BP)…Still Polyuric….. difficult to correct Lab: Urine…. Ca +++ Electrolytes ( Na, K, Cl, N..Mg), ABG …….↑pH, ↑HCO3, ↑pCO2 Key LAB report …..1. ↑R. 2.↑A USG… Nephrocalcinosis
A Poor Dehydrated Baby….
Triangular Face
Prominent Forehead
Large eyes
Strabismus
Protruding ears
Preterm…PolyHydramnios …polyuricHyponitremiaHypoKalemicHypochloremicMetabolic Alkalosis↑R ↑A
Autosomal recessiveAntenatal Diagnosis possible……K wasting Disorder…….
enin ldosteron
8days old …..Full Term baby….3.5kg….Severely Dehydrated ( 17% wt loss since birth)Didn’t respond to IV fluidRefractory to supportive t/tNo evidence of UTI, Obstructive uropathy
Lab…. ↓Na , ↑K ↓ pH, ↓HCO3, ↓pCO2
EVEN to A DOSE OF STEROIDES
↑ Sr Cortisol ↓17OH prog ↑ Sr Renin ↑ Sr Aldosteron
……CAH
Severe Dehy + Meta Acidosis +Hyponitremia+HyperKalemia
RESPONSE TO STEROIDS
Yes NO
• Pseudohypoaldosteronism (PHA) refers to a group of disorders characterized by apparent renal tubular unresponsiveness to aldosterone as evidenced by hyperkalemia, metabolic acidosis, and variable degrees of renal sodium wasting.
• PHA has two major subtypes. • Type I usually manifests in infancy with hypotension, severe
sodium wasting, and hyperkalemia. • Type II (Gordon syndrome) typically manifests in late
childhood and adulthood.
Introduction to EBM Introduction to EBM [evidence based medicine] [evidence based medicine]
Can you intubate?
Alternatives to EBM • At least 7
- EBM, Eminence Based Medcine - EBM, Eloquence Based Medicine - VBM, Vehemence Based Medicine - PBM, Providence Based Medicine
- DBM, Diffidence Based Medcine - NBM, Nervousness Based Medicine - CBM, Confidence Based Medicine
Isaacs D, Fitzgerald D. BMJ 1999; 319: 1618
EBM Eminence based medicine
• The more senior the colleague, the less importance (s)he placed on the need for anything as mundane as evidence….
Making the same mistakes with increasing confidence over an impressive number of
years….
Isaacs D, Fitzgerald D. BMJ 1999; 319: 1618
EBM Eloquence based medicine
• The year round suntan, carnation in the button hole, silk tie, Armani suit, and tongue.
Sartorial elegance and verbal eloquence are powerful substitues for evidence…
Isaacs D, Fitzgerald D. BMJ 1999; 319: 1618
VBM Vehemence based medicine
• The substitution of volume for evidence…
…..is an effective technique for brow beating your more timorous colleagues
and for convincing relatives of your ability….
Isaacs D, Fitzgerald D. BMJ 1999; 319: 1618
PBM Providence based medicine
• If the caring practitioner has no idea of what to do next, the decision may be best left in the hands of the Almighty….
Too many clinicians, unfortunately, are unable to resist giving God a hand with the
decision making…. Isaacs D, Fitzgerald D. BMJ 1999; 319: 1618
DBM Diffidence based medicine
• Some doctors see a problem and look for an answer.
• Others merely see a problem.
• The diffident doctor may do nothing from a sense of despair…..
This, of course, may be better than doing something merely because it hurts the
doctor’s pride to do nothing….
Isaacs D, Fitzgerald D. BMJ 1999; 319: 1618
NBM Nervousness based medicine
• Fear of litigation is a powerful stimulus to overinvestigation and overtreatment.
In an atmosphere of litigation phobia, the only bad test is the test you did
not think of ordering….
Isaacs D, Fitzgerald D. BMJ 1999; 319: 1618
CBM Confidence based medicine
Applies only to surgeons….
Isaacs D, Fitzgerald D. BMJ 1999; 319: 1618
The choice is yours!
Thank you for your attention