water

1
?????? ? ????????? ??? ??? ?? ???????????? ?
????????
2
?????

• ???????? ?????? ? ????????? ?? ?? ??????? ????
  ???.
• ??? ???? ??????? ??????????? ?????? ? ?????????
  ?? ?? ???? ???? ???? ???? ????????? ????? ???.

3
(No Transcript)
4
??????? ?????? ???? ?? ????? ?????? ? ?????????
?? ?? ???? ? ?????

• ??????? ?? ???? ? ???? ????
• ??????? ??? ??????
• ??????? ???? ? ??? ?? ????

5

• ???? ?? ??? Total Body Water (TBW) ????
• ???? ???? ????? Intra Cellular Fluid (ICF)
• ???? ???? ????? Extra Cellular Fluid (ECF)
• ?? ???? 60 ???? ??? ??? ??
• ?? ????? ??? 75 ????
• ?? ???? 90 ????

6
16wks 6 birth 3 6
9 12 3y 6y 9y 12y
Age
Age TBW ECF ICF
16 wks 90 60 30
Birth 75 40 35
3 month 70 35 35
12 month 60 20 40
body weight
7
Age wise distribution of TBW wwwwwwwwwwwwwwwwwater
Age TBW ECF ICF
16 wks 90 60 30
Birth 75 40 35
3 month 70 35 35
12 month 60 20 40
8

• ??? ??????? ??? ????? ????? ?????? ?? ??? (TBW) ?
  ??? ???? ????? ??? (ECF) ?? ?????? ?? ??????? ???
  ???? ??? ? ????? ???? ???? ????? ?? ?? ?? ????
  ???????? ???.

9
??????? ??? ??????

• ?????? ???? ??????? ??? ????????? ? ????????
  ??????..... ?????? ??? ?? ??? ?? ????.... ??????
  ???? ??? ??? ??? ??? ?? ??????
• ?????? ???? ??? ?????? ???? ??????? ???????
  ???? ??????? ??? ??????..............??????
  ????????? ?????? ............. ???? ???? ????
  ????? ?? ???? ????????........... ?? 25 ???? ????
  ??????? ????

10
??????? ???? ??? ?? ????

• ?? ????? ????? ?? ?????? ??? ??? ?? ????.....
  ?????? ?????? ?????? ??????...... ??? ??????
  ???????? ?? ???? ????
• ?????? ??? ???....... ?????? ????? ??? ????
  ...... ?????......... ???? ??? ??? ? ???? ??????
  ?? ???

11

• ?? ????? ?? ??? ???? ????? ELBW ????? ?????
  ?????? ????? ??? ??? ?? ????? ?? ?????? ????? ??
  ?? ???? ?????? ???? ???? ???.

12

• ????? ??? ?? ???? ??? ?? ????? ???...........5-
  10 ????
• ?? ????? ??? ???...........10- 15 ????
• ??? ?? ??? ???? ???? ???? ????? ??? ?? ???? ??
  ????? ???? ???? ?? ???????????? ? ?????? ???? ??
  PDA? NEC? ?????? ??? ???? ??? ???.

13
Fluid compartment ,composition their
physiological regulation

• TBW ECF ICF
• (60) (20) (40)
• ECF Intravascular fluid Interstitial Fluid
• (20) (5)
  (15)
  
  

14
Electrolyte Composition
15
???? ????? ??? ????? ????? ?????? ???

• ??? ????? ???? ?????
• ?????? ?????? ??? ??? ???? ?? ??????? ??? ?????
  ???? ????? ?? ??????? ??? ???
• ????? ????? ????? ??? ??????? .....????? ????
  ??????? ????? ????
• ??? ??? ???? ???????....... ????? ???? ????? ????
  ?? ??????? ??? ???
• ???? ???? ?????? ?????????? ???? ....... ?????
  ???? ????? ???? ?? ??????? ??? ???
• ???? ???? ????? ????? ?? ???? ????? ???? ?????
  ....... ????? ???? ????? ???? ?? ??????? ??? ???

16

• ???? ???? ?????? ????? .......... ????? ???? ? ??
  ?????? ?? ????? ????
• ??? ????? ???? ?? ??????? ???? ? ??? ??? ?? ????
  ....... ?????? ?????? ???????? ??? ???? ????? ?
  ???

17

• ?? ??? ???? ??? ??? ??????? ???? ??? ??????
  ????? ????? ??? ?? ???? ? ???? ??? ?? ???? ????
  ???? ????? ??? ???? ???? ??? ???? ????.
• ?? ??? ?????? ???????? ????? ????? ?? ?????
  ?????? ?? ???? ?? 2- 4 ???? ??? ?? ???.
• ????? ???????? ??? ?? ?????? ?? ???? ???? ????
  ????? ????? ? ???? ?????? ??????????? ?? ???. ??
  ??????? ????????

18

• ?????? ?????????? ??? ? ???? ??????? .........
  ???? ?????? ?? ?????? ADH
• ?? ??????? ???? ?? ?????? ?? ?????? ???? ???
  ....... ????? ? ??? ????? ?????......??????
  ????? ????????????

19

• ????? ???? ?? ????? ?? ????? ?? ??? ????? 1- 4 ??
  ??/ ???????/ ????
• ??? ??????? ?? Insensible water Loss (IWL) ??
  ???? ???? ? ???? ?? ?? ???
• ??? ???????? ?? Trans Epidermal Water Loss (TEWL)
  ?? ????? ???? ?? ???? - ????? ????
  ???????
• - ?????? ????
• - ?????? ????? ??
  ?? ???
• - ????? ????? ????
  ???? ????
• - ?????? GA .............????TEWL

20
?????? TE

• ???? ????? ???
• ?????? ???? ????
• ?? ????? ?????
• ?? ???? ?????

21
Maturation of skin
Skin changes
22
Management of fluid electrolyte requirement

• Total fluid electrolyte requirement
• Resuscitation fluid Maintenance fluid
• Deficit fluid ongoing losses
• Maintenance fluid sensible water losses ( urine
  stool ) Insensible water loss (skin lung )
  
• Water for tissue growth
  
• IWL Fluid intake-Urine outputwt loss or
• IWLFluid intake-Urine output wt gain
• All, Resuscitation, maintenance, Deficit
  ongoing fluid are different in volume,composition
  rate of adminstration.

23
Fluid shifts / intakes

• Intracellular

Kidneys Guts Lungs Skin
Interstitial
IV
24
??? ????? ??

• ???? ?? ?????
• ?????????? ?? ??? ??????? ???? ??? ??????? ??
  ??????? ???? ......????? 30- 40 ?? ??/ ???????/
  ??? ?? ???? ????? ?? ?????? ??? ?? ???? ? 120 ??
  ?? /???????/??? ?? ??? ???

25

• ?? ????? ?? ????? ?????? ?? ?? ??? ????? ??
  ???(??? ?? ???? 28)? ????? ?? ?? ???? ????? ?????
  90 ?? ?? /???????/ ??? ?? ?????? ??? ?? ???? ?
  150 ?? ?? / ??????? /??? ?? ??? ???
• ????? ????? ?? ?? ???? ????? ?? ????? ??? 10 ??
  ?? / ???????/ ??? ? ?? ????? ??? ??? 7 ???? ????/
  ???????/ ??? ?? ???? ??? ??? ?? ????

26
Insensible water losses

• Evaporation loss through skin usually contributes
  to 70 IWL ,rest 30 is contributed by
  respiratory tract.
• Gestational age, postnatal age, and environmental
  factors determine the amount of daily insensible
  water losses through the skin .
• During the first few postnatal days,
  transepidermal water losses may be 15-fold higher
  in extremely premature infants born at 23 to 26
  weeks gestation than in term neonates

27

• Although the skin matures rapidly after birth,
  even in extremely immature infants, insensible
  losses are still somewhat higher at the end of
  the first month than in the term counterparts.
•  Prenatal steroid exposure is associated with
  substantially less insensible water loss (IWL) in
  premature infants .

28

• Incubators, heat shields, transparent plastic
  barriers, coconut oil application, caps shocks
  are effective in reducing insensible water loss.
• Thin transparent plastic barrier (e.g cling wrap)
  reduces IWL 50-70 without interfering thermal
  regulation of warmer.
• The emphasis in fluid and electrolyte therapy
  should be on prevention of excessive IWL rather
  than replacement of increased IWL.

29
Mean IWL in incubators during first week of life
Birth weight (gm) IWL(ml/kg/day)
750 -1000 82
1001 -1250 56
1251 -1500 46
gt1501 26
30
Factors affecting insensible water loss in
neonates

• Increased insensible water loss (IWL)
• Increased respiratory rate, increase tidal
  volume,
• Conditions with skin injury (removal of adhesive
  tapes)
• Surgical malformations (gastroschisis,
  omphalocele, neural tube defects)
• Increased body temperature 30 increase in IWL
  per oC rise in temperature
• High ambient temperature 30 increase in IWL per
  oC rise in temperature
• Use of radiant warmer (50) and phototherapy
  (40) increase in IWL
• Decreased ambient humidity.
• Increased motor activity, crying 50-70 increase
  in IWL
• Increase surface area to body wt ratio

31

• Decreased insensible water loss (IWL)
• Use of incubators
• Humidification Temp of inspired gases in head
  box and ventilators
• Dead space ventilation
• Use of plexiglas heat shields
• Increased ambient humidity
• Thin transparent plastic barrier

32
Babies requiring IV fluid therapy

• Neonates with lethargy and refusal to feed
• Moderate to severe breathing difficulty
• Babies with shock
• Babies with severe asphyxia
• Abdominal distension with bilious or blood
  stained vomiting

33
GUIDELINE FOR FLUID REQUIRMENT

• Day 1 Term babies and babies with birth weight gt
  1500gms
• A full term infant on intravenous fluids would
  need to excrete a solute load of about 15
  mosm/kg/day in the urine.
• The infant would have to pass a minimum of 50
  ml/kg/day.
• Allowing for an additional IWL of 20 ml/kg, the
  initial fluids should be 60-70 ml/kg/day.
• The initial fluids should be 10 dextrose with no
  electrolytes to maintain GFR 4-6 mg/kg/min.
• Hence total fluid therapy on day 1 would be 60
  ml/kg/day.

34

• Day 1 Preterm baby with birth weight 1000-1500
  grams
• Urine output similar to term baby however fluid
  requirement is more in preterm because of
  inreased IWL and increased weight loss(ECF loss).
• To reduce the IWL under warmer,there should be
  liberal use of socks,cap,plastic barriers.
• 80ml/kg/day of 10dextrose is adequate on day 1.

35

• Day 2 - Day 7 Term babies and babies with birth
  weight
• gt1500gm
• As infant grows and receives enteral milk
  feeds, the solute
• load presented to the kidneys increases
  and the infant
• requires more fluid to excrete the solute
  load.
• Water is also required for fecal losses and
  for growth
• purposes.
• The fluid requirements increase by 15-20
  ml/kg/day until a
• maximum of 150 ml/kg/day.
• Sodium and potassium should be added after 48 h
  of age
• and glucose infusion should be maintained
  at
• 4-6mg/kg/min

36

• Day 2 Day 7 Preterm babies with birth weight
  1000-1500 grams
• As the skin matures in a preterm baby, the IWL
  progressively decreases and becomes similar to a
  term baby by the end of the first week. Hence,the
  fluid requirement would become similar to a term
  baby by the end of first week.
• Plastic barriers, caps and socks are used
  throughout the first
• week in order to reduce IWL from the
  immature skin.
• Fluids need to be increased at 10-15 ml/kg/day
  until a maximum of 150 ml/kg/day.
• gtDay 7 Term babies and babies with birth weight
  gt1500 grams
• Fluid should be given at 150-160
  ml/kg/day.
• gtDay 7 Preterm babies with birth weight
  1000-1500 grams
• Fluids should be given at 150-160
  ml/kg/day and sodium
• supplementation at 3-5 mEq/kg should
  continue till 32-34
• weeks corrected gestational age.

37
Fluid Requirment
Birth wt (gm) Day 1 Day 2 Day 3-6 Day gt7
lt750gm 100-140 120-160 140-200 140-160
750-100gm 100-120 100-140 130-180 140-160
1000-1500gm 80-100 100-120 120-160 150
gt1500gm 60-80 80-120 120-160 150
38
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39
Additional allowances

• These are applicable more for very preterm baby
  due to increased IWL
• Radiant warmer -20 ml/kg/day
• Phototherapy -20 ml/kg/day
• Increased body temperature -10-20 ml/kg/day

40
GUIDELINES FOR ELECTROLYTE REQUIRMENT

• SODIUM
• Do not add on day 1.
• Start after ensuring initial diuresis(U.O. gt
  1ml/kg/hr), a decrease in serum sodium
  (lt130meq/L) or at least 5-6 wt loss.
• Term - 2 meq/kg/day
• Preterm- 2-3 meq/kg/day to begin with 3-5
  meq/kg/day after 1st week

41

• Failure to provide this amount of sodium may be
  associated with poor weight gain
• Very low birth weight infants on exclusive
  breast-feeding may need sodium supplementation in
  addition to breast milk until 32-34 weeks
  corrected age

42

• Potasssium
• Add from day 3rd after make sure baby has UOP
  of gt 1ml/kg/hr k lt5.5meq/L. caution must be
  taken for ELBW who develop severe hyperkalemia in
  initial few days of life.
• Both term preterm 2 meq/kg/day

43
Calcium

• Add from day 1st to all sick babies babies
• lt1500 gm
• 36-72 mg/kg/day of elemental calcium
  
• i.e 4-8 ml/kg/day of 10 calcium
  gluconate

44
Choice of fluid

• Give 10 Dextrose (wtgt1250gm) or 5
  Dextrose(wtlt1250gm) for the initial 48 hours of
  life.
• After the age of 48 hrs if the baby is passing
  urine 5 6 times a day, use commercially
  available IV fluid, such as Isolyte P.
• If the premixed solution is not available or
  baby requires higher GIR (Glucose infusion rate),
• Add normal saline (NS) 20 ml/kg body weight
  (which contains 3meq of Na /kg) to the required
  volume of 10 Dextrose. Add 1ml KCl/100ml of
  prepared fluid.
• To calculate the necessary fluid volume,
  determine the volume of fluid required for day of
  life . Provide this as 20 ml/kg of NS and the
  remaining as 10 Dextrose.

45
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46
Administration of IV fluid

• Use a microdrip infusion set which has a
  microdropper (where 1 ml 60 microdrops)
• In this device, number of drops per minute is
  equal to mL of fluid per hour (e.g. If ababy
  needs 6mL/hr provide 6 microdrops/minute)
• Before infusing IV fluid, check-
• o The expiry date of the fluid
• o The seal of the infusion bottle or bag for
  its intactness
• o That the fluid is clear and free from any
  visible particles
• Calculate the rate of administration, and
  ensure that the microdropper delivers the fluid
  at the required rate.
• Change the IV infusion set and fluid bag every
  24 hours even if bag still contains IV fluid
  (this can be a major source of infection).

47
MONITORING OF FLUID AND ELECTROLYTE STATUS

• Body weight
• Serial weight measurements can be used as a guide
  to estimate the fluid deficit in newborns.
• Term neonates loose 1-3 of their birth weight
  daily with a cumulative loss of 5-10 in the
  first week of life.
• Preterm neonates loose 2-3 of their birth
  weight daily with a cumulative loss of 15-20 in
  the first week of life
• Failure to loose weight in the first week of
  life should be an indicator for fluid
  restriction.
• Excessive weight loss in the first 7 days or
  later would be non-physiological and correction
  with fluid therapy.
• Clinical examination
• Infants with 10 (100 ml/kg) dehydration may have
  sunken eyes and fontanel,
• cold and clammy skin, poor skin turgor and
  oliguria.
• Infants with 15 (150ml/kg) or more dehydration
  would have signs of shock (hypotension,
  tachycardia and weak pulses)
• Dehydration should be corrected within 24hrs.

48
SERUM BIOCHEMISTRY

• Serum sodium and plasma osmolarity helpful in the
  assessment of the
• hydration status in an infant.
• Serum Sodium values should be maintained between
  135-145 meq/L.
• Hyponatremia with weight loss suggests sodium
  depletion and would merit sodium replacement.
• Hyponatremia with weight gain suggests water
  excess and require fluid restriction.
• Hypernatremia with weight loss suggests
  dehydration and require fluid correction over 48
  hours.
• Hypernatremia with weight gain suggests salt and
  water load and would be an indication of fluid
  and sodium restriction.
• URINE OUTPUT,SPECIFIC GRAVITY AND OSMOLARITY
• Urine output would be 1-3ml/kg/hr
• Specific gravity between 1.005 to 1.012
• Osmolarity between 100-400 mosm/L.
• Specific gravity can be checked by dipstick or
  by a hand held refractometer.

49

• Blood gas
• Useful in the acid base management of patients
  with poor tissue perfusion and shock.
• Hypo-perfusion is associated with metabolic
  acidosis.
• Fractional excretion of sodium (FENa)
• Indicator of normal tubular function but is of
  limited value in preterm infants due to
  developmental tubular immaturity
• Serum blood urea nitrogen (BUN), creatinine
• Serum creatinine is a useful indicator of renal
  function. There is an exponential fall in serum
  creatinine levels in the first week of life as
  maternally derived creatinine is excreted.
  Failure to observe this normal decline in serial
  samples is a better indicator of renal failure as
  compared to a single value of creatinine in the
  first week of life.

50
LABORATORY GUIDELINE FOR FLUID AND ELECTROLYTE
THERAPY

• Intravenous fluids should be increased in the
  presence of
• (a) Increased weight loss(gt3/day or a
  cumulative loss gt20)
• (b) Increased serum sodium (Nagt145 mEq/L)
• (c)Increased urine specific gravity
  (gt1.020) or urine osmolality
• (gt400mosm/L)
• (d)Decreased urine output (lt1 ml/kg/hr)
• Fluids should be restricted in the presence of
• (a) Decreased weight loss (lt1/day or a
  cumulative loss lt5)
• (b) Decreased serum sodium in the presence
  of weight gain (Nalt130mEq/L)
• (c) Decreased urine specific gravity
  (lt1.005) or urine osmolality
• (lt100mosm/L)
• (d) Increased urine output (gt3 ml/kg/hr)

51
Monitoring of babies receiving IV fluid

• Inspect the infusion site every hour.
• Look for redness and swelling around the
  insertion site of the cannula, which indicates
  that the cannula is not in the vein and fluid is
  leaking into the subcutaneous tissues.
• If redness or swelling is seen at any time, stop
  the infusion, remove the cannula, and establish a
  new IV line in a different vein.
• Check the volume of fluid infused and compare to
  the prescribed volume, record all findings.
• Measure blood glucose every nursing shift i.e. 6
  8 hours.
• If the blood glucose is less than 45 mg/dl, treat
  for low blood glucose
• If the blood glucose is more than 150 mg/dl on
  two consecutive readings - Changeto a 5
  Dextrose solution and measure blood glucose again
  in three hours

52

• Weigh the baby daily. If the daily weight loss is
  more than 5, increase the total volume of fluid
  by 10 ml/kg body weight for one day to compensate
  for inadequate fluid administration.
• If there is no weight loss or there is weight
  gain in the initial 3 days of life, do not give
  the daily increment, keep the fluid rate same as
  the previous day ,however, if there is excessive
  weight gain (3-5) decrease the fluid intake by
  15-20 ml/kg/day.

53

• If there are signs of overhydration (e.g.
  excessive weight gain, puffy eyes, or increasing
  oedema over lower parts of the body), reduce the
  volume of fluid by half for 24 hours after the
  overhydration is noted. Check Serum Na, Urine
  specific gravity titrate fluid accordingly.
• Check urine output Normally a baby passes urine
  5 6 times everyday. If there is decreased urine
  output and weight loss increase fluid intake by
  10-20mL/kg
• However, if there is decreased urine output with
  weight gain, decrease daily fluid volume by
  10mL/kg and evaluate for renal failure.

54
Adjusting IV fluid with enteral feeding

• Allow the baby to begin breastfeeding as soon as
  the babys condition improves.
• If the baby cannot be breastfed, give expressed
  breast milk using an alternative feeding method .
  
• 
  
  If the baby tolerates the
  feed and there are no problems, continue to
  increase the volume of feeds by 20-30mL/kg/day,
  while decreasing the volume of IV fluid to
  maintain the total daily fluid volume according
  to the babys daily requirement.
• Feed the baby every two hours, adjusting the
  volume at each feeding accordingly.
• Discontinue the infusion of IV fluid when the
  baby is receiving more than two-third of the
  daily fluid volume by mouth and has no abdominal
  distension or vomiting.
• Encourage the mother to initiate breastfeeding
  as soon as possible

55
Replacement of fluid deficit therapy

• Moderate (10) to severe (15) dehydration fluid
  deficits are corrected gradually over 24 hours.
• For infants in shock, 10-20 ml/kg of normal
  saline is given immediately over 20 minutes
  followed by half correction over 8 hours. The
  remaining deficit is administered over 16
  hours.the volume of bolus should include in the
  initial half correction.
• the replacement fluid after correction of shock,
  should consist of N/2 composition.
• This fluid and electrolyte solution should be
  administered in addition to the maintenance fluid
  therapy.
• Assuming a deficit of 10 isotonic dehydration in
  a 3 kg child on day 4, the fluid calculation
  would be as follows
• (a) Dehydration replacement 300 ml of
  N/2 saline over 24 hours
• (150 ml over 8 hours and 150 ml
  over 16 hours)
• (b) Maintenance fluids 300 ml(100
  ml/kg/day on day 4) of N/5 in
• 10 dextrose over 24 hours

56
Ongoing losses

• Volume by volume replacement is needed(in
  addition to maintenance fluid) in situation like
  diarrhea chest tube drainage,excess gastric
  aspirate,surgical wound drainage and excessive
  urine loss.
• Estimate losses over 6-12 over.Replace urinary
  losses only if total lossgt4 ml/kg/h in 6 hr
  priod.Replace the volume that is in excess of
  4ml/kg/h-volume by volume over next 6 h.Other
  losses replaced volume for volume every 6 h

57
Type of fluid

• Vomiting, NG aspiration, excess urine output in
  polyuria (gt4ml/kg/h) Replace with N/2 saline
  10meq/L KCL (0.5 ml KCL added every 100 ml of
  fluid)
• Chest tube drainage, third space losses with NS
• Diarrheal losses (10-20 ml/stool) with N/5 in D
  5 20 meq/L KCL (1 ml KCL added every 100 ml of
  fluid).

58
SPECIFIC CLINICAL CONDITIONS

• Extreme prematurity (gestation lt28 weeks, birth
  weight lt1000 grams)
• These babies have large insensible water losses
  due to thin, immature skin barrier.
• Fluid requirements become comparable to larger
  infants by the end of the second week.
• Fluid requirement in the first week may be
  decreased by
• Plastic transparent barriers
• Coconut oil application
• Double walled incubators
• The initial fluids on day 1 should be electrolyte
  free and should be made using 5 dextrose
  solutions to prevent risks of hyperglycemia.
• Sodium and potassium should be added after 48hrs.

59

• Perinatal asphyxia and brain injury
• Perinatal asphyxia may be associated with
  syndrome of inappropriate ADH (SIADH) secretion.
• Fluid restriction in this condition should be
  done only in the presence of hyponatremia(lt120
  meq/L) due to SIADH or if there is renal faliure.
• The intake should be restricted to two-thirds
  maintenance fluids till serum sodium values
  return to normal.
• Once urine production increases by the third
  postnatal day, fluids may be gradually restored
  to normal levels.

60
Renal faliure

• Pre renal faliure account for 75 cause of ARF
• When a baby has not passed urine in the past 12
  hrs, the first thing is to look for distended
  bladder by palpation of the abdomen . It is
  better to avoid catheterization of the bladder to
  prevent infection,.
• After confirming the absence of urine in the
  bladder, a fluid challenge can be given. a
  normal saline bolus of 10 mL/kg can be given over
  20 min (or 20 mL/kg over 2 hrs). In spite of the
  fluid challenge, if urine output fails to ensue,
  frusemide can be given in a single dose of 1
  mg/kg (in a non dehydrated patient )

61

• Fluid management
• Fluids must be restricted to insensible water
  loss (IWL) along with urinary loss. The urinary
  loss must be replaced volume for volume 8 hrly.
  The insensible water loss in a term neonate is 25
  mL/kg/day. In preterm neonates, this can vary
  between 40-100 mL/kg/day depending on gestation,
  postnatal age, use of radiant warmers,
  phototherapy etc.
• The insensible water losses should be replaced
  with 5-10 dextrose. The urine output should be
  replaced volume by volume with N/5 saline.

62
RDS

• Surfactant deficiency results in pulmonary
  atelectasis, elevated pulmonary vascular
  resistance, poor lung compliance, and decreased
  lymphatic drainage.
• In addition, preterm infants have low plasma
  oncotic and critical pulmonary capillary
  pressures and suffer pulmonary capillary
  endothelial injury from mechanical ventilation,
  oxygen administration, and perinatal hypoxia .

63

• These abnormalities alter the balance of the
  Starling forces in the pulmonary
  microcirculation, leading to interstitial edema
  formation with further impairment in pulmonary
  functions.
• In the presurfactant era, an improvement in
  pulmonary function occurred only during the 3rd
  to 4th postnatal day. This improvement was
  usually preceded by a period of brisk diuresis
  characterized by small increases in glomerular
  filtration rate and sodium clearance and a larger
  rise in free water clearance .

64

• because significant improvements in lung
  function take place only after the majority of
  the excess free water is excreted , daily fluid
  intake should still be restricted to allow the
  extracellular volume contraction
• The renal function in preterm babies may be
  further compromised in the presence of hypoxia
  and acidosis due to RDS.
• Positive pressure ventilation may lead to
  increased secretion of aldosterone and ADH,
  leading to water retention

65

• If this principle is not followed and a positive
  fluid balance occurs, preterm infants with
  respiratory distress syndrome are at higher risk
  for a more severe course of acute lung disease
  and have a higher incidence of patent ductus
  arteriosus, congestive heart failure, and
  necrotizing enterocolitis as well as a greater
  severity of the ensuing bronchopulmonary
  dysplasia..

66
BPD

• higher fluid intake and lack of appropriate
  weight loss in the first 10 days of life are
  associated with significantly higher risk for
  bronchopulmonary dysplasia, even after
  controlling for other known risk factors such as
  those listed previously.

67
PDA

• Under physiologic circumstances in the immediate
  postnatal period, renal prostaglandin production
  is increased to counterbalance the renal actions
  of vasoconstrictor and sodium- and
  water-retaining hormones released during labor
  and delivery .
• Compared with the renal function of the adult
  kidney in euvolemia, the neonatal kidney is more
  dependent on the increased production of
  vasodilatory and natriuretic prostaglandins,
  rendering it more sensitive to the
  vasoconstrictive and sodium- and water-retaining
  actions of cyclooxygenase inhibition.

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• Therefore fluid management of the preterm infant
  receiving indomethacin must focus on maintaining
  an appropriately restricted fluid intake and
  avoiding extra sodium supplementation.
• As the prostaglandin inhibitory effects of
  indomethacin diminish following the last dose,
  renal prostaglandin production returns to normal,
  and the retained sodium and excess free water are
  usually rapidly excreted, especially with the
  improvement in the cardiovascular status as the
  ductal shunt decreases.

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• In clinically symptomatic or echocardiographically
  diagnosed PDA, it is recommended to restrict
  parenteral fluid intake to 120 mL/kg/day,
  provided other parameters like urine output,
  serum Na, urine specific gravity etc are within
  normal limits
• Infants on full enteral feeds with hs-PDA a
  fluid intake of up to 150 ml/kg/day may be used
  and calorie density may be increased in case of
  inadequate weight gain

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Polycythemia

• A) Symptomatic poycythemia or HCT gt75
• The definitive T/t is PET
• PET involves removing some of the blood volume
  and replacing it with normal saline so as to
  decrease the hematocrit to a target hematocrit of
  55.
• Volume to be exchanged
• Blood volume x (observed hematocrit desired
  hematocrit) /Observed hematocrit
• B) IF HCT b/w70 to 74
• Conservative management with hydration i.e.
  Hemodilution may be tried in these infants. An
  extra fluid/feeds of 20 mL/kg may be added to the
  daily fluid requirements. The additional fluid
  may be ensured by either enteral (supervised
  feeding) or parenteral route (IV fluids).

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SIADH

• SIADH may be associated with birth asphyxia,
  intracerebral hemorrhage, respiratory distress
  syndrome, pneumothorax, and the use of continuous
  positive-pressure ventilation .
• The treatment is based on fluid and sodium
  restriction despite the oliguria and
  hyponatremia, as well as on appropriate
  circulatory and ventilatory support. The
  clinician must remember that total body sodium is
  normal, but TBW is elevated in such an infant,
  and that it is particularly dangerous to treat
  the hyponatremia caused by free water retention
  with large amounts of sodium

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Shock

• The most frequent etiologic factors responsible
  for neonatal shock are inappropiate
  vasoregulation dysfunction of immature
  myocardium not absolute hypovolemia.
• Therefore,particularly in premature infant during
  the immediate postnatal period, fluid
  resuscitation Is recommended to be minimized
  especially when they have immature myocardium to
  tolerate acute fluid load.
• However absolute hypovoluemia is a major
  contributing factor to neonatal shock in neonates
  with sepsis and/or in postoperative peroid in pt
  undergoing major surgery.so early aggressive
  fluid therapy is indicated in these pt.
• Dose- 10-20 ml/kg of NS over 20-30 min
• Bolus should not be repeated unless there is
  convincing response to first bolus (falling HR
  ,improve CRT..)

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Key home messege

• Always add deficit ongoing losses and subtract
  volume of blood product, fluid boluses drugs as
  cal gluconate from maintenance fluid and
  remember special condition before prescribing
  fluid.
• Fluid recharting needs to be done every 6-12 hrly
  on the status of hydration.
• Prefer infusion pump, if not available use
  paediatric micro-drip set (60microdrops 1 ml)
• Never load more than 4 h fluid in microdrip
  set(especially during transport)
• Check sign of inflammation at the site of
  insertion of cannula check patency of cannula.
• Weight has a key role in monitoring fluid
  therapy. So assure regular precise weight
  measurement.

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Evaluation

• Preterm 33 weeks neonate, weighing 1.4 kg with
  breathing difficulty is brought to SCNUon D1 of
  life. The health care provider has decided to
  provide IV fluids along with othersupportive
  treatment.
• 1. What IV fluid you would start? How much
  volume of IV fluid is needed and at whatRate?
• 2. After 48 hours this baby still needs IV
  fluids. What changes in IV fluids are required.
• 3. Babys respiratory distress settled on day 3
  and he was started on minimal feeds.Today on day
  4 he is on 3 ml 2 hrly feeds of EBM. How will
  you adjust the IV fluid?

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• 4. What are the steps of monitoring this baby
  who is on IV fluids?
• 5. On D 7 of life baby is receiving 9 ml of EBM
  every 2 hours. How will you adjust IV fluids?
• 6. When will you stop IV fluids in this baby.

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References

• Averys Disease of The Newborn,9th edition
• Manual of neonatal care (Cloherty) seventh ed
• Care of Newborn seventh ed (Meharban singh)
• NELSON textbook of pediatrics,19th edition
• GHAI essential pediatrics,eighth edition
• AIIMS Nicu protocols 2014
• PGI Nicu protocols 2012
• NRHM SNCU Guidelines

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Breast milk is a best fluid made by God
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