Fluid management in newborns by Dr sonali

hello guys this is my third video presentation today we’ll be discussing the fluid management in newborn babies now this is starting further I would like to thank you for the excellent response that I have to say for my nation for presentations and thanks to that motivation we’ll be continuing in continuing for many more such topics in unit emerging now why do we need to discuss the fluid management in new one the neonatal poly food facility is very different from all the children as well as from adults the fluid and electrolyte requirement in a newborn it varies as for the weight and the gestational age of the baby as well as the postnatal age of the same child from time to time the tongue and the feet on babies they vary in their fluid and electrolyte quantity requirement as well as the composition requirements the improper fluid and electrolyte management in a newborn by itself can result in serious morbidity and even mortality in the baby now just to brush up the basic physiology intracellular fluid and extracellular fluid the intracellular fluid is the one which is present inside the cells that is in the between the cytoplasm of the cells and the extracellular body fluid it further is divided into two types that is saying dusty shelf node and the intravascular flow the interstitial fluid is the one which is been present between the root cells and the intramuscular fluid that is the plasma which is present in the vascular compartment now the ECF is the fluid which we regulate directly and the ICF is influenced by that now let us discuss my intrauterine physiology as well as the postnatal physiology what happens this will help us in getting an idea about how and wife lubing give the fluid to a new one in the particular strength I mean the early gestation the baby has a higher total body water content and a larger extracellular compartment as such a station advances there is rapid cellular growth and increased body solids and fat deposition and which results in reduction in the total body water content the reduction in the ECF volume and the increase in ICF volume therefore a premature infant has excess of total body fluid and the ECF volume expansion is more in a premature infant as compared to our term devil now this is a graph which gives us the idea about the body composition it consists of the total body water the muscle mass and the fact now as you can see the more premature a baby is the total body water content is more that is for a preterm baby the total body water constitutes to around 80 to 90 percent of the total body composition the muscle mass is very less in these babies and fat is almost negligible as the gestation proceeds term baby has approximately 70 to 80 percent of total body water content and it has a comparatively more fat mass as well as Muslim us the body water content progressively decreases and the muscle mass and the fat increases as the baby grows up now what happens during labor and delivery as we all know labor or the delivery mechanism there is a relative hypoxia during this period because of the inter from hypoxia there is increase in the capillary permeability this is further helped by the catecholamines which are released that is the forty-seventh of vasopressin they increase the arterial pressure further the resultant is that there is a fluid ship from the vascular compartment from the inter station during this time now once the baby is born there is increased oxygenation and there is increase in the way so active hormone production the resultant of these two factors is that the capillary permeability which was initially disturbed is now restored therefore there is interest heal fluid resorption in the vascular compartment so as we have seen in the early postnatal period there is interstitial fluid absorption resorption in the intravascular compartment that is not end is that there is a rise in the circulating blood point in response to this the heart releases a and B which is the atrial natriuretic peptide this enhances the sodium and water expression because of this there is an abrupt decrease in the total body water and the resulting the baby loses weight in the first week of life this is known as the physiologic diuresis phase what are the goals of a

fluid therapy anymore the first and foremost is to maintain the appropriate ECF for you secondly to maintain the ECF volume as well as the osmolarity of the extracellular as well as the intracellular fluid compartment and thirdly to maintaining maintain the any concentrations and pH of life now the steps which are required for doing this are estimating the existing deficits or excess that is we need to assess whether the child hydration status wise is normal is the child dehydrated or is the child over hydrated then we need to calculate the ongoing maintenance needs of this baby this is in form of the sensible fluid loss as well as the insensible fluid loss and to supply the additional needs and ongoing losses now this fluid which we supply is then calculated as per the IV and the oral fluid which we give to the baby now the four pillows in a newborn channel can be of two types it can be in the form of sensible water nose and insensible bottles sensible water loss is the one which is lost through the kidney and the GI tract that is in the form of urine and the water loss through the faeces for a baby the insensible water loss 70 percent of it is constituted by transit PW that is the water loss through skin and approximately 30 percent is lost through the respiratory guests discussing a little about the insensible water loss this is known as insensitive as this process is the one over which organisms have little physiological control this includes as we discussed the trance epidermal what a loss as well as the fluid loss through the respiratory tract against the insensible water loss is more in the preterm as compared to a term baby the reasons being that the steam barrier of a premature baby is in nature these babies generally have respiratory distress syndrome because of which there is increased active Nia and because of which this baby loses a lot of water content through the expired gases then there is a larger body water content there is more surface area as compared to the body mass for fluid loss also these are the babies infants and Ernie their interventions like ventilatory support the formers are used which further increase the insensible water loss now the gestational age the postnatal age and environmental factors it determines the insensible bottles ambient humidity is also one of the greatest determines the other environmental factor includes the activity of the baby the airflow the elevated body and environmental temperature skin breakdowns and the mucosal defects for example in a child with gastro crisis there will be a high influenceable water loss now the respiratory insensible water loss is mainly dependent on the temperature and humidity of the inspired gases the respiratory rate of the baby the tidal volume and the dead space ventilation now this is the this is the table which shows us approximate insensible water loss as for the birth weight and the postnatal age of the week as we can see for a micro preemie in the first seven days of life the baby can lose approximately 100 cc 4 kg per day of water through insensible means if the baby is approximately 1.75 to 2 kg the water loss can be as less as 15 cc 4 kg 40 and again for the next second week of life then sense will bottle as has been mentioned the values of iawn the increase is approximately around 30 with phototherapy exposure that is for photo therapy unit and the radiant warmers for the release the insensible water loss by approximately 50% now these are the factors that affect the iwi as we know maturity because the insensible portal nose is inversely proportional to the birth weight and the gestational age of the people it is lesser the world rate or the more premature baby there will be higher in sensible protein loss radiant warmers generally increase the water loss by around 50% incubators are therefore preferred for smaller and very premature babies photo therapy increases the water loss by 30 percent increasing humidity can decrease insensible total loss to approximately 30 percent and using plastic heat shields or even oil application on the skin of the baby can decrease the water nose bear on 31st so what are the ways to minimize or insensible Mortimer’s incubator news that is using at least that is minimum

of 50 percent of humidity the new mid efficacious of the inspired gases which we give to the baby that is oxygen which is supplied in the head box all the gases through until eaters maintaining a thermal neutral temperature for the baby increasing the ambient humidity use of thin transparent plastic barriers even use of local oil applications can minimize the evaporative losses from the skin of the child minimal and optimum use of stickings on the baby skin these are generally used for either the formal proof or the pulse oximeter probes and proper newborn skin care is very must to prevent more of the insensible water losses and as we have discussed humidification of the ventilator gases is very helpful because this can bring down the water loss as well as these help to prevent the valve bundles that is ventilator-associated pneumonia chances are decreased by using humidifier heated and humidified ventilated asks how do we assess whether the baby has optimum hydration status or no history of the baby has to be noted a body weight has to be recorded daily and charting has to be done then tachycardia if present may indicate hype or hypovolemia and this baby has to be looked properly the perfusion of the baby has to be checked every time the baby is touched that is a capillary refill time we expect it to be less than 30 seconds look for the presence of edema hepatomegaly blood pressure recording has to be done at least twice a day the skin turgor the mucous membrane then anterior fontanelle these are not very good and reliable signs then urine output of the child has to be calculated every day because decreased urine output can be the earliest sign of dehydration and systemic examination should be done to look for signs of RDS or PPD or even congenital heart disease and accordingly the fluid calculations will change now the laboratory parameters that we need to do is first and foremost the serum electrolytes the serum sodium and potassium has to be done on the day of admission as well as day 3 that is post the diuretic phase and it will alternative estimation has to be done for ventilated or unstable babies and twice weekly or even once a week are enough for other babies for on IV fruits the create and b1 has to be checked twice a V glucose estimation is very essential this has to be done twice a day for a mentholated on unstable baby for rest of the babies once daily is enough the plasma osmolarity has to be checked normal expected is 280 to 300 million small for later Yudin specific gravity of the child has to be checked it has to be in the range of one point zero zero eight one point zero one two and this has to be correlated with the plasma osmolarity especially for a ventilated and sick baby because we can find out the early starting of SIADH and accordingly fluid restriction can be done blood gas analysis has to be done to look for pH of normal eating especially metabolic acidosis efficient offer very early and septic workup has to be done for a dehydrated child coming over to how much should be the maintenance fluid for the initial two days of life that is one initial 48 hours the child has to be started on I will fluid containing only glucose no electrolytes to be added calcium maintenance can be added from day one itself now for a child who is extremely low birth weight that is less than 1 kg the dextrose concentration to be used can be 5% and accordingly the sugar monitoring has to be done and then we can decide whether the child needs 7 point 5 or 10% concentration it takes truth for a baby who’s more than 1 kg we can start off with 10% dextrose with calcium in it that’s fluid weight for a baby whose birth weight is less than 1 kg is approximately 100 cc per kg per day for the initial 24 hours and for a baby with birth weight more than 1.5 kg it can be as less than 60 64 kg holding the fluid is increased by 20 cc’s per kg for a day in the next consecutive days and the maximum is 160 CC per kg per day which can be achieved by day five or six of life or fatigue as we have discussed that maintenance calcium can be added from day one itself electrolytes need to be added after 48 hours of life that is after the initial diuretic phase of the baby has finished during the first week the requirement of sodium potassium is approximately one to two minutes well and four kg per day and beyond the first week it can go as high as two to three

minute column for kg per day the signs that show us the appropriate fluid and electrolyte balance in the child is that the child has a normal urine output which should be around 1 to 3 cc per kg for are the urine specific gravity should be between one point zero zero eight to one point zero one to a weight loss of 5% in a turn baby and 15% in freedom baby is expected a weight loss of two to three percent per day is expected in the first week of life the serum electrolytes status should be normal and there should be a normal weight graph on charts now let us consider certain special circumstances where we need to change our floor management first and foremost is a spirit or distress syndrome as it is the most common of morbidity which is seen associated with prematurity know consists of three phases the pre diuretic diuretic and the post diuretic fees as per our management the prebiotic phase can be known as the stabilisation things the eye retic is the restriction maintenance fields and the post diuretic is the liberalisation phase now what changes do we do in a baby in a third list fluid is restricted to two-third of maintenance during the initial phase after the unisys is occurred the fluid rate can be then costly cautiously increased and by seven to ten days of life we can reach the 160 cc per kg for prevention of hypoglycemia is very essential if the baby seemed to be in shock it can be treated with normal saline bolus with or without inotropic support full maintenance fluid can be achieved at the end of the first week once the initial diuresis is completed and special care has to be taken for calculating the insensible fluid losses and supplying them because these are the babies were generally requiring ventilating supports in the initial days itself also as they are more and more premature the transrapid on the water nurse can also be in my excess these are the ones who will require radiant – almost so we need to calculate the in surgical fluid losses and supplies for a baby with birth asphyxia now polyuria or annular may be seen in these babies secondary to either sid8 that is syndrome of inappropriate antidiuretic hormone secretion or renal injury in both of things we need to restrict the fluid to 2/3 of the main thing is during the period of anuria or all urea restoring the fluid intake to normal then the urine production is normal fluid push can be given in criminal course is suspected this can be given as 20 CC 4k to normal tonight or sometimes we may give even fanciful 480 in to any quotes the normal cell and push has to be given over a period of 15 to 20 minutes at least coming over to Peyton ductus arteriosus now the most important thing to remember in theory is that the PDA requires fluid restriction only and only if it is symptomatic that is it requires no restriction only if there are signs of failure in the instance of a fat oh my golly anymore or sudden weight gain which can be seen in the baby we supply 2/3 of the total maintenance fluid in this case that is there is one third restriction and IV furiosa mind may be given if need arises we generally try to avoid elastics that is we try to avoid the furiosa mind because it has the side effects which can be very or dangerous for the baby the first thing that we normally encounter it is electrolyte imbalance specially hyperkalemia and the most important thing that we are worried about is sensory neural hearing loss which can result in the baby due to improper use of diuretics now when we encounter a baby who has acute renal failure nowadays the term acute renal failure is obsolete because we know all it as a few kidney injury eki when a baby has not fast urine in the past 12 hours the first thing to look for is distended bladder the palpation of the abdomen or ultrasound now generally palpation of abdominal is enough if the bladder is distended we can catheterize the baby and relief for the even if again and again this has to be done then we look for ultrasone what is the impending force now after confirming the absence of urine in the bladder a fluid challenge can be given as we have discussed fluid challenge can be given in a bolus that is it can be given as a normal saline bolus of fencing say 4 kg over a period of 15 to 20 minutes and it can be repeated twice

in spite of the fluid challenge if the urine or four fails to enter then purism ID can be given in a single dose 0.5 to 1 MJ per kg in a non dehydrated patient is it it is very important that before giving serious in life we look for signs of dehydration in the child as well as we document a normal blood pressure reading for this chain notes must be restricted to insensible water loss plus urinary losses the urinary loads must be replaced volume 4 volume the instance even water loss in a term neonate is approximately 25 cc per kg folding in a freedom unite this can vary between 40 to 160 4 kg per day depending on the gestation of the baby the postnatal age the use of Radian formers photo therapy or even ventilators now the fluid requirement should be revised based on the urine output the weight and assessment of the EC of volume status preferably every 8 RT the insensible water loss should be replaced by 5 to 10% dextrose and the urine output should be replaced volume by volume by 1/5 of normal saline during the polio rick phase the army monitoring of urine output and serial monitoring of serum electrolytes with appropriate replacement of sodium potassium and water run indicated for prevention of dehydration hyponatremia and hypokalemia to conclude maintaining fluid and electrolyte is one of the most and most important duty requirements in a newborn Barry’s as for the maturity the birth weight and the postnatal each of the shine the total body water content is higher in a freedom child and out of that approximately 2/3 is the easy folding maintenance fluid of a child is the total of sensible rottenness that is through urine and suits and the insensible for tumors that is transfer phenomena and respiratory water us the use of incubators humidifiers plastic shields and local body oil application they help in minimizing the insensible water loss skin turgor mucous membrane dryness are not very reliable indicators for dehydration in any of one and instead the weight charting perfusion heart rate size of the liver are more sensitive indicators flow fluid status in the baby the initial fluids are started in dextrose calcium can be added on the day 1 of life itself and electrolytes are added after the initial diuretic phase is finished that is roughly around 48 hours of life the fluid requirements are different in special situations like a flute renal failure symptomatic PDF spirit syndrome even birth asphyxia and we have already discussed them in details now fluid restriction has to be done in PD only if it is symptomatic careful management of fluids and electrolytes goes a long way in successful management of an infant so this concludes our presentation on the fluid management hope this will help you in proper management of newborn baby if you like this presentation do click on the like button which is present out there and do subscribe to the channel neonatal her I’ll try to bring out new topics for our discussion further all your queries all your suggestions are most welcome keep watching thank you