You are on page 1of 64

FLUID & ELECTROLYTE

THERAPY
Rhishikesh Thakre
DM (Neonatology)
MD, DCH, DNB, FCPS.
PRINCIPLES
Understand the physiology of fluid changes
Balancing act between intake 8 output
Naintain 8 support body growth
!ndividualize the approach
Fluid Compartments
Total body water in 2
body compartments
Intracellular fluid (ICF)
Extracellular fluid (ECF
- Interstitial space
- Intravascular space
1
st
week ECF volume
decreases
Isotonic
Hypotonic
Hypertonic
92%
86%
77%
72%
66%
62%
60%
45%
30%
28%
26% 26%
32%
42%
38%
36%
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
0 3 6 9//0 3 6 9
TBW
ECF
ICF
B
o
d
y

W
a
t
e
r

C
o
n
t
e
n
t

(
%
)
FETUS NEWBORN
Age (months)
100
90
80
70
60
50
40
30
20
10
0
%
C
o
m
p
o
s
i
f
i
o
n

o
f

b
o
d
y

f
I
u
i
d
s
+ + - - + + - -
+ + - -
100
Cations
Na 140 143 010
K 004 004 160
Anions
Cl 104 114 002
HCO3 025 029 008
Na HCO3
Cl
Na
HCO3
Cl
K
Mg
Na
HCO3
Pr
PO4
200
Plasma ISF ICF
o
K
P
o
K
P
Insensible water loss
Not obvious : Skin (2f3) 8 Resp tract (1f3)
Depends on:
gestational age (more PT: more !WL)
postnatal age (skin thickens with age)
SWL that seen = urine+stool
+0 20 60 > 12 yr
+0 30 70 1 m-12 m
35 +5 80 Newborn
ICF ECF TBW
Handicaps in newborn
Water content is high
Renal immaturity
!nsensible water loss
Small variation of fluids have grave
implications
Fluid overload : PDA, CLD, !vH..
Long term neurologic sequelae
GOAL :
Prevent dehydration & hypoglycemia
HYDRATION ELECTROLYTE
DEXTROSE
Fluid Therapy Order :
How much fluid ?
What fluid ?
What rate ?
Any additives - Na, K, Dext, Ca ?
What to monitor ?
Special situations :
Dyselectrolytemia, Hypoglycemia, Shock,
Oliguria, Polyuria
How much fluids ?
1. Naintenance :
Preterm vs Term
2. Deficit :
Determined by acute weight change
3. Ongoing losses :
Determined by measuring gastric aspirate, !CD
drainage, blood loss, Urine output
Maintenance Fluid
60
> 2500
100
750-1000
80
1000-2500
120
Fluids
(mlfkgfd)
< 750
Body Wt
(gm)
!ncrease total fluid intake 20 ccfkgfday
Goal : 160-180 ccfkgfday
Fluid Requirements
DECREASE
PDA
CCF
CLD
ARF
S!ADH
INCREASE
Radiant warmer
Phototherapy
3
rd
Space losses
Fever
Cold stress
Omphalocele
Neningomyelocele
Deficit therapy
150 15 Severe
100 10 Noderate
50 5 Nild
Deficit fluid
ccJkg
% of weight
loss
Degree of
deficit
Composition
ICF (mEqfL) ECF (mEqfL)
Sodium 20 135-145
Potassium 150 3-5
Chloride --- 9S-110
Bicarbonate 10 20-25
Phosphate 110-115 5
Protein 75 10
Rate of fluids
Calculate 2+ hr requirement
Rate (micro dropsfmt) =
volume of Fluid (ml) f 2+ h
Mode of administration
Enteral :
Bolus
!ntermittant
-
Parenteral :
Slow
Continuous
Uniform
vascular access
Umbilical access
!ntra osseous
Commercial fluids
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 NS
585 154 154 50 5% DNS
Dextrose,
electrolyte
solution
556 100 10%
278 50 5%
Electrolyte
free
solution
154 77 77 NS
isotonic
270 2 29 111 5 131 RL
308 154 154 NS
Isotonic
gm/L
mOsm
/L
Ca Lact
ate
Cl K Na Dextr.
~ For hypoglycemia correction
~ For increasing glucose conc
25 % D
~ IV Maintainence for > 1000g for
first 24 48 h
~ For hypoglycemia correction
10 % D
~ IV Maintainence for < 1000 g
first 24 - 48 h
~ Vehicle for ACT, Aminophyline,
Calcium gluconate
5 % D
I N D I C A T I O N
F L U I D
What fluids to use ?
~ Maintenance IV fluid ( > 48 h) Isolyte P
~ Correction of symptomatic
hyponatremia
3 % NS
~ Replacement of ileostomy loses NS
~ Volume expander in shock RL
~ Volume expander in shock
~ Vehicle for phenytoin, Sodabicarb,
Aminophyline
~ Replacement of gastric aspirate
~ Correction of hyponatremia
NS
What fluids to give ?
Na K Cl HCO3
Gastric juice 20-80 15 125 0
Small-intestinal 100-1+0 15 155 +0
Diarrhea 10-90 +0 +0 +0
Sweat normal 10-30 10 25 0
Sweat CF 50-130 15 75 0
Electrolytes in Body Fluids
{mEqJL)
Gastric aspirate : Replace with NS
!leostomy loses : Replace with NS
Glucose Requirement
Optimum requirement 4- 6 mg / kg / min
Conc. Used - 5%, 10%, 12.5% (max)
High risk newborns
LBW, IDM, IUGR, Sick.
Maintain sugar > 45 mg%
GIR : Rule of thumb
3 mlJkgJhr of 10% D = 5mgJkgJmin
To achieve 7 mgJkgJmin
D5W: !v rate (in mlfhr) =
8.+ X Body Wt (in kg)
D10W: !v rate (in mlfhr) =
+.2 X Body Wt (in kg)
Glucose infusion rate
15.6 12.5 6.25 1S0
13.0 10.+ 5.2 150
10.+ 8.3 +.2 120
7.8 6.25 3.1 90
5.2 +.2 2.1 60
mgJkgJmin of dextrose
12.5% D 10% D 5% D
Intake
{mlJkgJday)
Algorithm for hypoglcyemia mgt
High risk
Asymptomatic
Symptomatic
Neonate
Level > 45 - 50
with feeds
Level low with feeds or
doesn't take feeds
Continue
feeds and
monitoring
Start IV Glucose @ 4
- 6 mg/kg/min
Give bolus @ 200
mg/kg followed by
IV Glucose @ 6 - 8
mg/kg/min
Electrolytes
None required in first 2+-+8 hours :
exception infant < 1000 g
Na : 2-+ meqfkgfday
K : 1-2 meqfkgfday
Calcium : For all preterms
!onised Ca <0.9 (PT) or 1.1 (T)
Physical signs
Urine output
Daily weight
Urine specific gravity
Blood urea
Hematocrit
How to monitor fluid therapy ?
Assessment of fluid and
electrolyte status
History:
Baby's F8E status partially reflects mom's F8E
status (Excessive use of oxytocin, hypotonic !vF can
cause hyponatremia)
ACE inhibitors, Aminoglycoside, Frusemide,
Aspirin given to mother can alter neonatal
renal function
Physical Examination:
Weight :
Reflects TBW
Not very useful for intravascular volume
eg. Long term paralysis and peritonitis can lead to
increased body weight and increased interstitial
fluid but decreased intravascular volume.
Noral : a puffy baby may or may not have
adequate fluid where it counts: in his blood
vessels
Assessment of fluid &
electrolyte status
Physical Examination
SkinJMucosa: Altered skin turgor, sunken AF,
dry mucosa, edema etc are not sensitive
indicators in babies
Cardiovascular :
Tachycardia can result from too much (ECF excess in
CHF) or too little ECF (hypovolemia)
Delayed capillary refill can result from low cardiac
output
Hepatomegaly can occur with ECF excess
Blood pressure changes very late
Clinical monitoring of fluid
therapy
Weight record - 1 - 2 loss per day
8 hourly wt record
BP and perfusion - intravascular volume
Urine output - 1 - + mlfkgfhr
All 3 are not accurate in a criticall ill
neonate
Hence we need lab estimation of `lytes'
Lab Assessment of F & E
Serum electrolytes
Plasma osmolarity
Urine electrolytes, specific gravity
(not very useful if the baby is on diuretics)
BUN, S creatinine
(values in the 1
st
week reflect mom's values)
ABG
(low pH and bicarb may indicate poor perfusion)
Asphyxia : FLUIDS
Restrict fluids : Depending upon severity
UfO < 1 ccfkgfhr over 6 hrs = oliguria
Persistent seizures f altered sensorium
warrant Na f K estimation
High K = Ongoing hemorrhage f Adrenal
Persistent low Na is an ominous sign
Asphyxia : FLUIDS
Correction of acidosis : Hypokalemia
Do not routinely supplement calcium
Persistent hypocalcemia f hypokalemia
warrants magnesium evaluation
Avoid hypo or hyper-glycemia
Hypoglycemia : Bolus f Push ?
RDS : Fluids
Restrict fluids during the acute phase
Watch for diuresis : Increase fluid rapidly
Avoid hypervolumia during entire therapy
No weight loss or static weight in first 72 hrs
Isolated diastolic shock is an early marker of
opening of PDA in RDS during recovery
PDA : Fluids
Symptomatic : restrict fluids
Presence of isolated diastolic low blood
pressure is an earliest marker of opening
of ductus
Weight gain : development of CCF
Ensure normokalemia before digitalizing
If no response to CCF in 24 hrs, check
electrolytes
SHOCK : Fluids
Ensure fluid expansion before starting
pressors
Colloids vs crystalloids
Oliguria with shock warrants CvP
monitoring
SHOCK : Fluids
Concomitant hypokalemia worsens hyperglycemia in
septic shock
Persistent hyperglycemia therefore warrants
potassium estimation
High hematocrit with shock : severe intravascular
depletion
Unexplained shock with hyperkalemia : adrenal
pathology
ARF : Fluids
U/O not a reliable indicator for ARF
Presence of oliguria, unexplained weight
gain warrants renal chemistry
Check electrolytes :
Low Na = fluid retention
High Na = renal tubular pathology
ARF : Fluids
Ensure hydration by +0 - 60 ccfkgfd !vF
(isotonicfdextrose) + Urine output (2+ h)
for calculating fluid requirements over
next 2+ hours
Hyperkalemia is a medical emergency
!ncrease fluids during the polyuric phase
to maintain hydration
Sodium
Nost important cation in extracellular fluid space
Kidneys are the primary organ in regulating Na
balance
ROLES
Depolarization : Nuscles, Nerves
Affect Total body water
Affect Water distribution
Cotransport :Glucose, aminoacids etc.
Approach to hyponatremia
ECF Excess Excess !vF, CHF,
Sepsis, Paralysis
Restrict fluids
ECF Normal Excess !vF, S!ADH,
Pain, Opiates
Restrict fluids
ECF Deficit Diuretics, CAH, NEC
(third spacing)
!ncrease
sodium intake
Mgt OF Hyponatremia
Na deficit =
0.6 x wt (kg) x (desired Na - current Na)
Neurological Signs or Na+ <120 mEq f lit
Treat promptly
What to give : 3 NS (2 - + ml fkg)
NaHco3 7.5 solution =
0.9 mEq Na+ f ml (if 3 Nacl not available)
Correct underlying etiology
CSW & SIADH
SIADH CSW
Cr. clearance N Jincreased NJdecreased
Blood urea N Jdecreased NJincreased
Urine volume N Jdecreased NJincreased
Body weight StableJincreased NJdecreased
Correction of Hyponatremia
Thumb rule -
Correct 1f3rd 8hr
1f3rd 16 hr
1f3rd 2+ - +8 hr.
Plasma Na > 145 mEq
Dehydration +
in shock
Normal ECS
( partially treated )
Hypervolumia
Fluid boluses (NS)
Restore volume
+ Deficit ( 10%)
Replace
free water + maint.
In > 48 hours
Diuresis
Dialysis
Mgt OF Hypernatremia
Estimate total body fluid deficit
clinically or by change in weight
Rate of decrease should not exceed
0.5-1 mEqfLfhr
Rapid correction in hypernatremia
may result in rebound cerebral edema
Mgt OF Hypernatremia
Free water deficit may be estimated as +
ccfkg of free water needed for every mEqfL
the Na+ is over 1+5 mEqfL
Deficit will be replaced with free water (D5, or
D10)
Remainder of deficit (total body fluid deficit -
free water deficit) is replaced with NS
POTASSIUM
Principal intracellular cation
Affects intracellular osmolarity
Affects cell volume
Roles :
PRODUCES REST!NG 8 ACT!ON POTENT!ALS
COTRANSPORT
THERNOGENES!S
COFACTOR FOR PROTE!N SYNTHES!S
Normal K
+
Balance
Najor cation of !CF
98 in !CF
ICF ECF
K+ 98% K+ 2%
Dynamic equilibrium
Calculate Potassium deficit
K+ deficit =
(Req K - obs K) x bodywt.
3
Mgt OF Hypokalemia
KCl is the preferred drug in all patient
Max K+ iJv
without ECG = +0 mEq f lit
with ECG = 60 - 80 mEq f lit
Correct the underlying disorder
Mgt OF Hyperkalemia
1. Check sampling error
2. Stop all Potassium containing fluids
3. Cal gluconate : !n arrhythmia 0.5
cfkg. Nay be repeated twice
+. Sodabicarb, 2 - 5 ccfkg
5. Glucose (0.5-1 gmfkg) + !nsulin
(0.1-0.2 unitsfkg) !v push
6. Kayexalate 1 g fkg, 6-8 hr
7. Dialysis
GOLDEN RULES :
With acidosis, the potassium rises, while
it drops with alkalosis
For every rise of 100 mg of sugar
above 100 mg sodium decreases by
1.6 meqfl
Deficits of chloride are 2f3 of sodium
Do not give K till urine output established
Practical Tips
First 2+ - +8 hrs of life use only Dextrose
A newborn's fluid and electrolyte (FE)
status partially reflects the mother's FE
status
Deduct aminoacids, drug volume, blood
products, pressors from the total !vF
Patient Rounds
Report total 2+ hr intake 8 mlfkgfday
Report what part of total intake was oral
v.s. intravenous v.s. G-tube
Report total 2+ hr output 8 mlfkgfday
Report where this output came from
(urine, chest tube, stoma, gastric
residue etc)
Daily weight
Electrolyte Contents
7 mEq of Na 1 cc conc. RL
1 mEq of Na 1 cc NaHCo 3 { 7.5 % )
2 mEq Na 1 cc KCL { 10 % )
3.8 mEq Na 1 cc KCL { 15 % )
2.5 mEq Na, 2 mEq K 100 cc Isolyte P
51.3 mEq of Na 100 cc 3 % NS
15.4 mEq of Na 100 cc of 0.9 % NS
Concentration I V F L U I D
Conclusions
Appropriate fluids 8 electrolyte therapy
constitutes basic neonatal care
Be judicious and meticulous about fluids
Avoid inadvertent iatrogenic errors
THANK YOU THANK YOU THANK YOU THANK YOU

You might also like