hello to the group, we need opinions on the hydro-electrolyte management in children under 28 weeks. we have problems to regulate the weight loss and not to exceed in volume.

What volume do you start with?
How much weight loss do they tolerate?
How much sodium do they provide in this first week?

How do you manage patients with high diuretic rhythms that give basal needs greater than 200 ml/kg ? do you replace it ?

When a patient loses more than 15% of weight, what strategies do you use to regain it?

thank you very much 

 

Hi Juan Carlos, extreme preemies have greater renal immaturity, they do not handle water well and many have polyuria. I have reviewed different guidelines and some of them recommend starting with volumes of 100 to 140 cc.k.day (CSPEN), 80 - 100 cc.k.day (ESPGHAN).

Ideally the preterm should not lose more than 3% of its weight per day. We use relative humidity in the incubators up to 90%. We give sodium 2 to 4 meq.k.day in the first week, then we give 5 to 8 meq.k.day

when the patient loses more weight than normal, it is evaluated if this due to poor caloric or hydric intake. If the problem is negative water balance, increase by 20cc.k.day the following day

 

Hi Juan, we would start per the ESPGHAN recommendation at 80-100 ml/kg/d and increase by ~15-20 ml/kg/d depending on weight, sodium-levels and urinary output. I agree with @Rossana that the ideal weight loss is rather small, but we often see larger weight losses and hypernatremia >145 mmol/L in practise... We also use very high humidity initially and we focus more on hydration/water losses than sodium supplementation the first week, we supplement similarly as described above.

High urinary output, we do not replace exact volumes but consider it may adjust total volumes ~12 hourly when needed. We routinely check for u-glucose in those circumstances, just in case we have missed hyperglycemia and osmotic diuresis.

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Hi all,

There is no magical number but i agree you have to start frow somewhere. For < 28 GA we usually begin around 100 ml/kg/d with 1 mmol/kg/d (essentially  from drug) but the key is to adapt and adjust according to your patient in the following days.

There are two way to loose water : diuresis and insensible water loss (skin++). And one for Na (diuresis).

You can measure diuresis but not water loss. There is no anti-diuresis medication but you can reduce your IWL with an high humidity. And when you already have lost too much water you have to replace it.

There will be always a delay between the urinary output and your input's adaptation, and you can not be sure of your IWL.  So even with a correct input adaptation you will have some suprises with an unexpected weight loss or with natremia. 

About humidity, we aim 90 - 95 % humidity at least. We always have issue with non water proof incubator (they seems to be water proof only when they are brand new...) and sometimes we barely reach 90-95 %. Nurses also complain about condensation at 99 % humidity.

After saying all this good words, i have to say we still have hydro electric balance issues with < 28 GA. We had improvement over the last years. One thing that helped us is to do the right thing at the right moment. I explain, we manage the hydroelectric balance with 4 parameters (weight, natremia,input, output). In our NICU, we used to weigh  babies between 8pm and 2 am, to change the prescription in the morning, to plugged the new PN lines between 2 pm and 6 pm, to do the blood test 5am or 8am, and to measure the diuresis every 3 hours. And so the prescription of the PN was done with an 12 hour old weight and at the time we were having a new weight the new lines were plugged for 4 - 6 hours. Now, we weigh every < 28 GA at the same times as the blood test (5 or 8 am) and ask the new lines to be plugged as soon as the prescription is done in the morning. I am not in favor of micro management, because you end up doing the opposite 3h later. You have to let some time from your previous interventions to  reasses before doing a new one. I rather adapt once or twice a day but to do so you have to have the right informations at the right moment.

And just an another remark, i don't know how you are working in other country but sometimes i do what i can do with what i have. Reading people or guidelines  about intakes it seems easy to set the Na at xx ml/kg/d or H2O at xx ml/kg/d  or dextrose at xx g/kg/d. Well, in real life when i prescribe a drug it comes with water +/-Na, add Phosphore it comes with Na, add proteins it come with water, our PN for the first days is a D10 % Na/K free or not but i can't decide the level, < 28 GA have some times high glycemia with low Dextrose intake. It is all about a compromise.

 

Edited September 4, 20223 yr by Pyw
Mispelling

thank you very much, I feel very identified with your words, from the literature to the patient's bedside there is often an abyss, and often there are no diseases but only patients and their circumstances. equally, evidence is the best tool we can have, but we have a lot to learn from these immature children