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INTRAVENOUS Fluids.

Things to consider:

• Normal changes in the TBW and ECF

• Changes in the salt and water balance

• Normal changes in the renal function

• Insensible water losses.

Body fluid composition in the Fetus and Newborn

• TBW= ICF+ECF(intravasular and interstitial)

• As gestational age increases TBW and ECF decreases while ICF increases

• At birth TBW=75% of body weight in term infants and 80% in preterm infants.

TBW- changes according to age

Perinatal changes

• During first week to 10 days of life reduction in body weight is due to reduction in the ECF

• Term infants weight loss = 5%-10% with in 3-5 days of life.

• Preterm Infant lose about 10%-15% of body weight with in 5 days of life.

Sodium balance in the newborn

• Major cation and Anion of ECF are sodium and chloride respectively.

• Major Cation of ICF- potassium and Anions are protein, organic acids and phosphate.

• Sodium balance is maintained by 3Na-2K pump .

• Plasma Osmolality ranges from 285-295 mOsmos/kg

• Osmolality= 2(Na)+1/8(Glucose)+BUN/2.8

Sodium balance in the newborn

• Renal sodium loses are inversely proportional to gestational age of the child

• Term infants have fractional excretion of Na-1% with transient increase on day 2 and

• Preterm infants <35 wks have a negative sodium balance and hyponatremia during first 2-3 wks of life

Sodium balance in the newborn

• Increased urinary sodium losses seen in

-Hypoxia

-Respiratory Distress

-Hyperbilirubinemia

-ATN

-Polycythemia

-Diuretics

Renal concentration and diluting Capacity

• Adults can concentrate urine upto 1500mOsm/kg of plasma water and dilute as low as 50mOsm/kg of plasma water.

• Concentrating capacity is 800mOsm/kg in term infants and 600mOsm/kg in preterm , so require more urine volume to excrete solutes

• Diluting capacity is 50mOsm/kg in term infants and 70mOsm/kg in preterm

• Newborns have reduction in GFR and decreased activity of transporters in the early distal tubule

Insensible loss of Water.

• Maturity of the Infant(BSA/Kg)• Open Warmer bed• Phototherapy• Hyperthermia • Tachypnea• Reduced by -Enclosed incubator

-Humidified Air-Sedation-Decreased Activity-Hypothermia

Who require IV Fluids

• Infant <30 weeks, & <1200 gm• Sick Term Newborns and children

-Severe Birth Asphyxia-Apnea-RDS-Sepsis -Seizure-Hemodynamic Instability-GI malformations-Shock

How Much Fluid to be Given:Neonates

Birth Weight Day1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

<1000 g 80 100 120 130 140 150 160

1000-1500 g 70 90 110 120 130 140 150

>1500 g 60 75 90 105 120 135 150

How Much Fluid to be Given:Infants and >1 year

Maintenance IV F -Holiday- Segar method

First 10kg 100ml/kg(4ml/kg/hr)

Next10-20kg Add 50ml/kg(2ml/kg/hr)

>20kg Add 20ml/kg(1ml/kg/hr)

How Much Fluid to be Given

Maintenance IV Fluids-Bed side Calculation

Age Ml/kg/day

<1 yr 120

1-2 yr 110

2-3yr 100

3-4yr 90

4-5yr 80

5-6yr 70

>6-yrs 60

Type of Fluid

.1st 48 hrs- <1000g: 5% Dextrose

>1000g: 10% Dextrose

· 48hrs- 28 days : 10% DN/6

(80ml NS+ 420ml 10% Dextrose)

. 28 days-6 yrs : 5% DN/4

. 6 Yrs-12 yrs : 5% DN/2

. >12 yrs : 5% DNS

Composition of IV fluidsIV fluid Dextr Na K Cl lactate ca MOsm/l

NS - 154 - 154 - - 308

RL - 131 5 111 29 2 270

1/2NS - 77 - 77 - - 154

5%D 50 - - - - - 278

10%D 100 - - - - - 556

5%DNS 50 154 - 154 - - 585

5% DNS/2

50 77 - 77 - - 415

5% DNS/4

50 34 - 34 - - 347

Isolyte P 50 29 20 29 - - 368

5% DNS/6

50 25 - 25 - -

Extra Fluid

• Warmer –add 10ml/kg/day

• Phototherapy-add 10ml/kg/day

• Fever- increase fluid requirement by 12% per degree rise above 37.8 degree C

• Tachypnea- increase fluid requirement 10-30%

Extra Fluid

• NEC and other condition with 3rd space loss

• ELBW and VLBW Neonates

• Vomiting

• Gastroenteritis

• Shock

• Burns

• Tachypnea

• DKA

Less Fluid

• Birth Asphyxia

• Meningitis

• Intra Ventricular Hemorrhage

• PDA(cardiac failure)

• Oliguria/Anuria

• SIADH

• Edema

Special Situations

• Oliguria-Insensible water loss + measured urine output + deficit

• Anuria-Insensible water loss + deficit

• Dehydration- Maintenance + Deficit + ongoing losses.

MonitoringParameter Freque

ncyNormal value

Fluid deficit signs Fluid overload signs

Bed side.

1.Clinical 8hrly - Loss of skin turgor, dry mucosa, tachycardia

Puffiness of eyes, sudden increase in liver size , basal rales

2.Weight Daily Weight loss Sudden weight gain

3.Urine Volume 6-8 hrly 1-3ml/kg/hr

<1 ml/kg/hr >3 ml/kg/hr

4.Urine Specific Gravity 6-8 hrly 1008-1015 >1015 <1004

Laboratory

1. Urine Osmolality 12hr 100-300 >450 <100

2. Plasma osmolality Daily 285 >300 <270

3.Serum Na 24-48hr 135-145 - -

4.Serum K 24-48hr 4-5 - -

5. Blood urea 24-48hr 20-40 - -

6. Serum Creatinine 24-48hr 0.6-1.2 - -