Fluid and Electrolyte Management

• Sources of water loss

1. Renal losses.
• homeostasis is common in the preterm infant. Contributing factors
leading to varying urinary water and electrolyte losses include the
following:
a. Decreased glomerular filtration rate (GFR)
b. Reduced proximal and distal tubule Na reabsorption
c. Decreased capacity to concentrate or dilute urine
d. Decreased bicarbonate, potassium (K), and hydrogen ion secretion

2. Extra renal losses. In VLBW infants, IWL can exceed 150 mL/kg/day
owing to increased environmental and body temperatures, skin break
down, radiant warmers, phototherapy, and extreme prematurity
• in intubated infants inadequate humidification of the inspired gas may
lead to increased IWL

• Other fluid losses that should be replaced if amount is deemed significant

include stool (diarrhea or ostomy drainage), cerebrospinal fluid (from
ventriculotomy or serial lumbar punctures), and nasogastric tube or
thoracostomy tube drainage.
II. ASSESSMENT OF FLUID AND ELECTROLYTE STATUS
A. History
1. Maternal. The newborn's fluid and electrolyte status partially reflects
maternal hydration status and drug
administration. Excessive use of oxytocin, diuretics, or hyponatremic
intravenous (IV) fluid can lead to maternal and fetal hyponatremia. Antenatal
steroids may increase skin maturation, subsequently decreasing IWL and the
risk of hyperkalemia.

2. Fetal/perinatal. The presence of oligohydramnios may be associated with

congenital renal dysfunction,
Severe in utero hypoxemia or birth asphyxia may lead to acute tubular
necrosis.
• B. Physical examination

• 1. Change in body weight. Acute changes in an infant's weight generally

reflect a change in TBW. The weight should be measured at least daily.
• 2. Skin and mucosal manifestations. Altered skin turgor, sunken anterior
fontanelle, and dry mucous
• membranes are not sensitive indicators o
• 3. Cardiovascular. Tachycardia can result from ECF excess (e.g., heart
failure) or hypovolemia. Capillary refill time and hepatomegaly can occur
• with increased ECF volume. Blood pressure changes occur late.
C. Laboratory studies:

1. Serum electrolytes and plasma osmolarity. Frequent monitoring, every 4

to 6 hours, should be done in the extremely low birth weight (ELBW) infants
during the first few days of life owing to high IWL.
2. Fluid balance
with immature renal function, urine output may not decrease despite ECF
volume depletion.
3. Urine electrolytes and specific gravity (SG) can reflect renal capacity to
concentrate or dilute urine and reabsorb or excrete Na.
4. Fractional excretion of Na (FENa) reflects the balance between
glomerular filtration and tubular reabsorption of Na. FENa = (urine Na ×
plasma creatinine) / (plasma Na × urine creatinine) × 100
a. Level of <1% indicates prerenal factors reducing renal blood flow.
b. Level of 2.5% occurs with acute renal failure (ARF).
c. Level of >2.5% is frequently seen in infants of <32 weeks' gestation.

5. Blood urea nitrogen (BUN) and serum creatinine (Cr)

6. Arterial pH, carbon dioxide tension (PCO2), and Na bicarbonate

 III. MANAGEMENT OF FLUIDS AND ELECTROLYTES

A. The term infant. Body weight decreases by 3% to 5% over the first 5 to 6

days

B. The premature infant. Allow a 5% to 15% weight loss over the first 5 to 6
days.
• APPROACH TO DISORDERS OF NA AND WATER BALANCE

A. Isonatremic disorders

1. Dehydration
2.Edema

B. Hyponatremic disorders

C.Hypernatremic disorders
1. Hypernatremia with normal or deficient ECF volume

a. Predisposing factors increased renal and IWL in VLBW

infants.
b. Diagnosis. Weight loss, tachycardia and hypotension,
metabolic acidosis, decreasing urine output, and
increasing urine SG may
c. Therapy. Increase free water administration to reduce serum
Na no faster than 1 mEq/kg/hour.

2. Hypernatremia with ECF volume excess

a. Predisposing factors include excessive isotonic or hypertonic
fluid administration
b. Diagnosis. Weight gain associated with edema is observed.
c. Therapy. Restrict Na administration.
• Disorders of k metabolism
Hypokalemia
hyperkalemia
TPN
Protein CHO
7-16% 40-50%

Lipids
40-55%
• To induce weight gain Give :

• 100–120 kcal/kg/d to a term infant (gain:15–30 g/d)

• 110–150 kcal/kg/d to a premature infant

• Carbohydrate. Dextrose (D-glucose) is the
carbohydrate source in intravenous (IV)
solutions
❑ The caloric value of dextrose is 3.4 kcal/g.
❑ The concentration administered through peripheral veins is limited to
≤12.5%
❑ Higher concentrations of dextrose may be used for central venous
infusions.
• The initial glucose requirement for term infants is defined as the amount
that is necessary to avoid hypoglycemia. In general, this may be achieved
with initial infusion rates of approximately 4 to 6 mg/kg/minute.

• Preterm infants usually require higher rates of glucose because they have
a higher brain-to-body weight ratio and higher total energy needs. Initial
infusion rates of 4 to 8 mg/kg/minute may be required to maintain
euglycemia.

• Daily increment of 1-2 mg/kg/m…maximum of 11-12 mg/kg/min

• GIR= glucose conc *rate /6 * weight

• Glucose (grams)=weight*GIR*24*60 / 1000

• Protein.
❑ The caloric value of amino acids is 4 kcal/g.
❑ Current recommendations support the infusion of amino acids at a dose of
2 to 3 g/kg/day beginning in the first 24 hours after birth.
❑ Protein infusion rates are increased to a target of 3.5 to 4 g/kg/day for
premature infants and up to 3 g/kg/day for the term neonates
• Lipids:
❑ The caloric value (≈ 10 kcal/g)
❑ infants <1,500 g at birth, 2 g/kg/day of lipids should be provided within
the first 24 hours after birth. This rate should be advanced by the next day
to a goal of 3 g/kg/day.
❑ Current data suggest that preterm infants are at risk for essential fatty acid
(EFA) deficiency within 72 hours after birth, if an exogenous fat source is
not delivered.
❑ This deficiency state can be avoided by the administration of 0.5 to 1
g/kg/day of lipid emulsion
• Decreased tolerance to IV lipids is frequently seen with infants
❑ <1,000 g birth weight, <27 weeks' gestation
❑ are small for gestational age, suffer from intrauterine growth restriction
❑ sepsis.
• Electrolytes
1. Sodium and potassium concentrations are adjusted daily based on
individual requirements.

Maintenance requirements are estimated at approximately 2 to 4mEq/kg.

• Minerals.
The amount of calcium and phosphorus that can be administered through
IV is limited by the precipitation of calcium phosphate. Unfortunately, the
variables that determine calcium and phosphate compatibility in PN are
complex and what constitutes maximal safe concentrations is
controversial.
• Three-in-one PN solutions are not used (dextrose, amino acid, and lipid
mixed in single bag) for the following reasons:
• a. The pH of lipid emulsions is more basic and increases the pH of the
total solution, which decreases the solubility of calcium and phosphorus
and limits the amount of these
• minerals in the solution.
• b. If the calcium and phosphorus in a three-in-one solution did
precipitate, it would be difficult to detect because the solution is already
cloudy.
• c. Three-in-one solutions require either a larger micron filter or no filter,
which may pose a greater sepsis risk.
• Trace elements and vitamins
Schedule for nutrition monitoring
• Potential complications associated with PN
1. Cholestasis: may be seen and is more often transient than progressive.
Experimentally, even short-term PN can reduce bile flow and bile salt
formation.
a. Risk factors include the following:
i. Prematurity
ii. Duration of PN administration
iii. Duration of fasting (lack of enteral feeding also produces bile
inspissation and cholestasis)
iv. Infection
v. Narcotic administration
b. Recommended management:
i. Attempt enteral feeding. Even minimal enteral feedings may stimulate
bile secretion.
ii. Avoid excess nutrition with PN.
iii. Provision of a mixed fuel source may be helpful.
iv. When conjugated bilirubin is >1.5 mg/dL, lipids may be decreased to 1
g/kg. If this change is made, the glucose infusion rate may need to be
increased to 14 to 16 mg glucose/kg/minute to meet energy needs
v.megaven made from fish oil and SMOF.
Metabolic bone disease .The use of earlier enteral feedings and central PN,
with higher calcium and phosphorus concentrations, has reduced the
incidence of
3. Metabolic abnormalities., hyperammonemia, and hyperchloremic
metabolic acidosis have become uncommon since introduction of the current
crystalline amino acid
solutions. These complications may occur, however, with amino acid intakes
exceeding 4 g/kg/day.
 • Metabolic abnormalities related to
4.
a. lipid emulsions, Hyperlipidemia/hypertriglyceridemia.
The AAP suggests serum triglyceride concentrations be maintained below
200 mg/dL.
b. Indirect hyperbilirubinemia. Because free fatty acids can theoretically
displace bilirubin from albumin-binding sites, the use of lipid emulsions during
periods of neonatal
hyperbilirubinemia has been questioned. Research, however, suggests that
infusion of lipid, at rates up to 3 g/kg/day, is unlikely to displace bilirubin.
However, during periods of extreme hyperbilirubinemia e.g., requiring exchange
transfusion), rates <3 g/kg/day are typically provided.