FLUID MANAGEMENT IN

NICU

Dr.L.Srividya
final yr pg
 OVERVIEW

Body water composition

Insensible water losses
Guidelines for maintenance fluids
Maintenance electrolytes
Glucose infusion rate
Monitoring of fluid and electrolyte status
Management in specific conditions
 Composition of Body Water
Total body water =Extracellular +
Intracellular fluids

ECF=Intravascular + Interstitial fluid

Insensible water loss = Fluid intake

Urine
output +
Weight change
 At birth ,75% of bodyweight is accounted for
by water.

Extracellular fluid compartment constitute

40% and intracellular fluid accounts for 30%.

By 3 months, intracellular and extracellular

fluid volumes become equal.

As gestational age progresses, smaller

proportion of body weight is composed of
water
Physiological changes in body water
**Proper understanding of
physiological changes in body water
and solute after birth is essential to
ensure smooth transition from
aquatic in-utero environment to dry
ex-utero environment**
Perinatal changes in total body water
After birth
Efflux of fluid from intracellular to
extracellular compartment

Salt and water diuresis by 48-72

hours.

Physiological weight loss in the 1st

week of life.
 Term infants loose upto 10% of birth
wt .

Premature infant looses upto 15%

birth wt.

Failure to loose extra cellular fluid is

associated with morbidities like
PDA ,NEC and chronic lung disease in
preterm neonates
 SOURCES OF WATER LOSS
Sensible water loss = water loss by
the kidneys and gastro-intestinal
system

Insensible water loss (IWL) =

water loss by evaporation from the
skin(70%) + respiratory tract(30%)

Insensible water losses tend to be

higher in preterm infants.
 Remember....
Kidneys in neonate have a limited
capacity to excrete both diluted and
concentrated urine.
Also has limited capacity to excrete
and conserve sodium.
Acceptable urine osmolality range is
300-400 mmol/L .
This corresponds to daily urine
output of
2-3ml/kg/hr.
 Why renal losses??

Reduced proximal and distal tubular

Na reabsorption
Decreased capacity to concentrate or
dilute urine
Decreased bicarbonate, potassium
and hydrogen ion secretion.
 Insensible water loss according to
birth weight on day 1
BIRTH INSENSIBLE
WEIGHT WATER LOSS
(ml/kg/day)

< 1000g 60-80

1000-1500g 40-60

>1500g 20
 Factors affecting insensible water loss in neonates
Increased insensible water loss (IWL)
Increased respiratory rate

Conditions with skin injury (removal of adhesive tapes)

Surgical malformations (gastroschisis, omphalocele,

neural tube defects)

Use of radiant warmer: 50% increase in IWL

Use of phototherapy: 40% increase in IWL

Increased motor activity, crying: 50-70% increase in IWL

 Decreased insensible water loss
(IWL)
Use of incubators
Humidification of inspired gases in head
box an ventilators
Increased ambient humidity
Thin transparent plastic barriers
*Main aim in fluid and electrolyte therapy
should be to prevent excessive IWL rather
than replacement of Increased IWL*
incubator
Transparent plastic barriers
 Principles of fluid
management
Total fluid and electrolyte
requirement = maintenance +deficit
+on going losses

Maintenance fluid
requirement=insensible water
loss(skin + lungs)+sensible water
loss(urine + stool)
 Guide lines for maintenance fluid
requirements in newborn
Day 1: Term babies (> 1.5kg):
A full term infant on intravenous fluids would need
to excrete a solute load of about 15 mosm/kg/day
in the urine.

To excrete this solute load at a urine osmolarity of

300 mosm/kg/day, 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 in order to maintain a glucose
infusion rate of 4-6 mg/kg/min
Why maintenance fluids should not
contain electrolytes for first 2
days???
Day2- Day 7:
As the 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

The fluid requirements increase by 15-20

ml/kg/day until a maximum of 150 ml/kg/day.

Na+ and K+ should be added after 48 hrs of

age and glucose infusion should be
maintained at 4-6 mg/kg/min
Day 1: Preterm baby (birth weight 1-1.5
kg)
The urine output in a preterm baby would
be similar to a term baby. However, the fluid
requirement will be higher due to increased
IWL and increased weight loss.

Use of caps, socks and plastic barriers

reduce the IWL under the radiant warmer.

80 ml/kg/day of 10% dextrose is the fluid

requirement.
Day 2 Day 7:
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.

The fluid requirement in a preterm baby, initially

higher due to increased IWL, would become similar
to a term baby by the end of the first week

Fluids need to be increased at 10-15 ml/kg/day

until a maximum of 150 ml/kg/day.
>Day 7: Term babies and babies with birth weight
>1.5kg

Fluids should be given at 150-160 ml/kg/day.

>Day 7: Preterm babies with birth weight 1-1.5kg

Fluids should be given at 150-160 ml/kg/day

Sodium supplementation at 3-5 mEq/kg till 32-34wks

corrected gestational age.
 Daily fluid requirements during first week of
life(ml/kg/day)

Birth Day1 Day2 Day3 Day4 Day5 Day6 Day7

weig
ht

<1kg 80 100 120 130 140 150 160

1 80 95 110 120 130 140 150

To
1.5k
g
>1.5 60 75 90 105 120 135 150
kg
 Additional allowances
Required for preterm babies due to increased
Insensible water losses.
Radiant warmer 20ml/kg/d
Photo therapy
single surface 20 ml/kg/d
double surface 40ml/kg/d
Increased body temperature 10-20ml/kg/d
* It is unnecesary to increase fluid intake
routinely on starting phototherapy if baby is
nursed in an incubator with humidification *
 What is GIR (glucose infusion
rate)???

GIR(mg/kg/min)
%dextrose conc X ml/kg/day of
fluid
=
144
 On day 3,to supplement electrolytes
along with mantaining a GIR of
6mg/kg/min, we use isolyte P and
25% dextrose.
Eg: for a 3kg baby on D3,fluid
requirement is 100ml/kg
so %D =GIR X 144
100
=( 6X144)/100 =9%
(approximately)
 So inorder to get 9%dextrose by
combining isolyte P and 25%dextrose
isolyte P(5%D) 25%dextrose

4% 16%
9%dextrose
Amount of isolyte P=(16/16+4)X TFR
= 4/5 XTFR
 Amount of
25%dextrose=(4/4+16)XTFR
= 1/5 X
TFR
 Maintenance electrolyte
requirement
Sodium
Sodium supplementation started after ensuring
initial diuresis(urine output >/=1ml/kg/hr)
atleast 5-6% of weight loss from birth
serum sodium<130meq/lit .
Term - 2meq/kg/day
Preterm - 2-3meq/kg/day to begin with &
3-5meq/kg/day after first
week
Potassium
Add from day 3(make sure that baby has
urine output of >/= 1ml/kg/hr & k<5.5 meq/l)
Both term and preterm : 2 meq/kg/day
Calcium- from D1
Preterm <32 wks (<1500 gms)
Infants of diabetic mothers
Severe asphyxia
4ml/kg/day of 10%calcium gluconate
 Composition of various IV fluids in
NICU(meq/L)
solution Dextrose Na K Cl mosm/L
(g/L)
5% 50 ------ ------- ____ 278
dextrose
10% 100 ------- -------- ____ 510
dextrose

50 25 20 25 350
Isolyte P

NS(0.9%) ----- 154 ____ 154 308

------- 77 ____ 77 154

NS(0.45%
)
Monitoring of fluid and electrolyte
status and planning further
increments of fluids
paramete frequency of Normal Fluid deficit Fluid
r monitoring limits overload
Clinical 8 hourly No signs of Loss of skin Puffy
signs deficit turgor , dry eyes,edem
overhydrati mucosa a,
on Increased
liver size.
wt term OD 1-2% per >2% per day Wt gain/no
day loss/<expe
preterm 12th hrly 2-3% per >3% per day cted loss
day
serum <750g 6-8 hrly
sodium till3-4d 135- >145meq/l <135meq/l
750-1500g 12hrly 145meq/l
till3-4d
>1500g daily
Urine vol 8 hourly 1-3 ml/kg/h <1 ml/kg/hr -
Urine sp Test each Sample 1005-1015 >1015 <1005
gravity voided
Urea & Initially & atleast rise in urea
creatinine every other day until Normal disproportiona
stable ,then weekly values te to -
 Other parameters
BLOOD GAS ANALYSIS:
not routinely used
only in case of poor tissue perfusion and shock

FRACTIONAL EXCRETION OF SODIUM(FENa):

(urine Na X plasma creatinine)

X 100
( plasma Na X urine creatinine)
Interpretation:
<1%- prerenal factors reducing renal
blood flow
2.5%-acute renal failure(ARF)
>2.5%-frequently seen in infants of
<32 wks gestation.
 Hyponatremia with weight loss- sodium depletion
- replace sodium
Hyponatremia with weight gain-water excess
- restrict fluid
Hypernatremia with weight loss-dehydration
- fluid correction over 48 hrs
Hypernatremia with weight gain-salt &water load
- fluid & sodium restriction
*maintain serum sodium between 135-145meq/l*
 Remember...
Normally, there is an exponential fall
in serum creatinine levels in the first
week of life due to excretion of
maternally derived serum creatinine.
Failure to observe this decline in
serial samples in first week is a
better indicator of renal failure than a
single serum sample.
 Intravenous fluids should be
increased if

(a) Increased weight loss(>3%/day)

(b) Increased serum sodium
(Na>145 mEq/L)
(c) Increased urine specific gravity
(>1.020) or
urine osmolality (>400 mosm/L)
 Fluids should be restricted if

(a) Decreased weight loss (<1%/day)

(b) Decreased serum sodium in the
presence of weight gain (Na<130
mEq/L)
(c) Decreased urine specific gravity
(<1.005) or urine osmolality (<100
mosm/L)
(d) Increased urine output (>3
 Fluid management in extremely
low birthweight babies (<1000g)
Larger insensible water losses due to thin
,immature skin.

Stratum corneum matures rapidly in 1-2 weeks

Fluid requirements become comparable to larger

infants by end of 2nd week.

Initial fluids on day1 is 5%dextrose

Na & k added after 48 hrs.
Why 5% dextrose??
 ELBW babies cant tolerate 10% dextrose due
to impaired glucose tolerance

Osmotic diuresis can increase dehydration(if

osmolarity>300mosm/l)

Risk of intracranial hemorrhage due to

contraction of intracellular volume of the
brain by rapid shift of water from ICF to ECF
due to increased osmolarity.
 DEHYDRATION
Diarhhoea
Vomiting
Necrotising enterocolitis
Gastroschisis
Open neural tube defects

Initial signs of dehydration:

Weight loss > 5% in a day
Oliguria < 1ml/kg/hr
 The usual physical signs of dehydration
are unreliable in neonates.

Infants with 10% (100 ml/kg) dehydration

may have sunken eyes and fontanalle, 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)
 Replacement of fluid deficits in
dehydration
Fluid deficit=preillness wt-illness wt
% of dehydration=
(preillness wt - illness wt) x100
( preillness wt)
In Moderate(10%) to severe
dehydration(15%),fluid deficits are gradually
corrected over 24 hrs.
Fluid correction for 10%dehydration-100ml/kg
15%deyhdration-150ml/kg
Preferably NS is used
 Half of the above said correction is
done over 8 hrs and remaining
correction over 16 hrs.
This correction is administered in
addition to maintenance fluid
therapy.
 FLUID MANAGEMENT IN PERINATAL ASPHYXIA
Two processes predispose to fluid overload in
asphyxiated newborns:

Syndrome of inappropriate antidiuretic harmone

secretion(SIADH)
Acute tubular necrosis resulting from diving reflex

Fluid restriction in this condition should be done only

in the presence of hyponatremia. The intake should be
restricted to two-thirds maintenance fluids till serum
sodium values return to normal.

Once urine production increases by 3 rd post natal

day,fluids may be restored to normal levels.
 RESPIRATORY DISTRESS
SYNDROME
Hypoxia and acidosis leads to
compromised renal function.
Positive pressure ventilation lead to
increased aldosterone and ADH
secretion leading to fluid retention.
Symptomatic PDA is more likely.
Strict fluid monitoring is
required.
 Renal failure:
Fluid requirement = IWL + Urine
output

Insensible water loss in a term

neonate is 25ml/kg/day

insensible water loss in a preterm

neonate is 40ml/kg/day
No electrolytes should be added.
Fluid of choice is 10% Dextrose
REVISE FLUID REQUIREMENT EVERY 8TH
HRLY BASED ON URINE OUTPUT.
 NECROTISING
ENTEROCOLITIS
Fluid therapy guided by urine
output,serum sodium,blood urea.

Replace gastric aspirates with half

normal saline with
kcl(1ml/100mlfluid) every 12th hrly
 REFERENCES
AIIMS NICU protocols
PGI protocols
Cloherty
Indian journal of paediatrics
Thank u...
 Pathological losses and deficit
replacement
In conditions like
Diarrhea with dehydration
Chest tube drainage,excess gastric
aspirates,surgical wound drainage and
excessive urine losses from osmotic diuresis
Estimate losses over past 6-12 hr
Replace urinary losses only if total loss
>4ml/kg/h in 6 hr period
Replace the volume in exce of 4ml/kg/h-
volume by volume over next 6-12 h
 Other loses are replaced volume for
volume every 6hr
In all vlbw babies,the calculation is
done every 6 hrly
 Type of fluid for replacement :
Vomiting, ng aspiration and excess urine
output in polyuria(>4ml/kg/hr) replace with
n/2 salinewith+10 meq/l kcl (0.5 ml kcl
added per every 100ml of fluid)
Chest tube drainage and third space loses
with ns
Diarrheal losses(10-20 ml per stool) with
0.2 ns in d5 + 20 meq/l kcl(1ml kcl added
every 100ml of fluid)