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SECTION

NEONATAL GUIDELINES
TITLE

GI / GU

NUMBER

460

Parenteral Fluid Management in Neonates

APPROVED BY Neonatal Patient Care Team

DATE

10/00; 11/03 04/07 1 OF 4

Original signed by Dr. John Baier

PAGE

1.0

PURPOSE: 1.1 To provide a process for administration and adjustment of parenteral and enteral fluids in neonates in the Neonatal Intensive Care Unit (NICU) and Intermediate Care Nursery (IMCN).

2.0

GUIDELINES 2.1 The physician (resident, fellow, house officer or staff) must write fluid orders at least once a day for all neonates that are receiving parenteral fluids according to the guidelines provided in this document. The physician must also write any deviations from the guidelines as an order. Fluid orders include: Total Fluid Intake (TFI) in mL/kg/24 hr with The weight on which the order is based included. All parenteral infusions including monitoring lines (e.g. UAC, arterial line). Adjustments should be made for fluid deficits or excesses, increased or decreased fluid losses or altered maintenance fluid requirements based on disease condition. Total Fluid Intake standard maintenance fluids are ordered according to the following guidelines: Day of Life 1 2 3 4 5 2.5 mL/kg/Day 65-80 80 100 120 135-150

2.2

2.3 2.4

Exceptions to the standard maintenance fluids are: 2.5.1 Start at least at 80 mL/kg/day on day 1 of life for Hypoglycemic infants of diabetic mothers. Infants less than 1000 gm birthweight. Infants with an omphalocele.

DATE

10/00; 11/03; 04/07

PAGE

2 OF 4

NUMBER

460

NEONATAL GUIDELINES
2.5.2 Infants with gastroschisis preoperative management: Start 150-200 mL/kg/day on day 1 of life. Initially use D5W with NS for infusion. Use D5W (not D10W) for all infusions to avoid excessive glucose intake.

2.6

Total Fluids Received (TFR) is calculated every 24 hours based on the following criteria: Fluid Source Inclusion Criteria Parenteral Infusions Include all Line flushes Considered a gift except: Intermittent medication infusions if total volumes are greater than 10% of ordered TFI or infant is fluid restricted and receiving less than 60% of usual expected maintenance fluids (as outlined above) Blood products (all varieties) Not usually included in TFI but are calculated into the TFR Fluid boluses Volume expansion boluses Exceptions to the inclusion criteria must be ordered by the physician The nurse will calculate the patients actual TFR, output and fluid balance a minimum of every 24 hours. This may be ordered at more frequent intervals (most often q6h) as patients condition requires. Fluid balance is assessed at 2400 hrs and at 6 hour intervals as required by the infants clinical status. The fluid balance includes total intake from enteral and parenteral sources and all measured output but does not include insensible water losses. Replacement fluids for losses (eg. gastric suctioning, chest tube) should not include glucose or potassium. Parenteral Infusion Guidelines: 2.12.1 Central lines with a diameter of 3 Fr or less have a minimum infusion of 1 mL/hr and must not be locked at any time as they have a high risk of losing patency when locked. Medication infusions are mixed in D10W unless otherwise ordered. Total glucose intake in mg/kg/min is calculated during morning rounds

2.7 2.8

2.9 2.10 2.11 2.12

2.12.2 2.12.3

DATE

10/00; 11/03; 04/07

PAGE

3 OF 4

NUMBER

460

NEONATAL GUIDELINES
from all parenteral and enteral sources for all patients in the first week of life with a birth weight of less than or equal to 1000g, those with documented hypoglycemia, or if patient is on insulin. 2.12.4 2.12.5 IV solution rates are adjusted to maintain TFI as the volume and schedules of enteral feeds are altered. When infusion rates must be increased, D10W is infused for piggyback or TKO [note: use current electrolyte solution, including Total Parenteral Nutrition (TPN), if any, until it expires] to maintain the minimal required infusion rate for each site. If the volume of feeds (plus) mandatory parenteral fluids exceeds the ordered TFI the physician must decide to either recalculate the TFI or limit the volume of feeds. When the volume of enteral feeds reaches 50% of the TFI, discontinue any lipid infusion. When the volume of enteral feeds reaches 75% of the TFI, D10W may be used to balance the TFI once the TPN or electrolyte solution expires. Insulin infusions are to be filtered and are to be run through the same type of tubing as the lipids (IVAC 30303). When starting a new insulin infusion, fill the tubing, allow it to sit for approximately 30 minutes, flush that fluid through (waste it) and then attach the tubing to the IV. When central lines have extremely small lumens (such as the doublelumen 1.9 Fr Argyle), consider adding heparin 0.5 unit/mL to the solution if compatible. Parenteral route is determined by the following guidelines: Infusion Normal saline with heparin 1 unit/ml @ 1mL/hr Normal saline @ 1mL/hr D10W, Medications (bolus and infusion), TPN or electrolyte solutions @ minimum 1mL/hr Normal Saline with Heparin 1 unit/ml @ 1mL/hr Electrolyte solutions, TPN. May be saline locked

2.12.6

2.12.7 2.12.8 2.12.9

2.12.10

2.12.11

Type of Line Arterial Line: Peripheral (radial, tibial, axillary) Arterial Line: Umbilical Central Venous Line Pressure Lines: Right Atrial (RA), Left Atrial, (LA), Pulmonary Artery (PA) Peripheral Intravenous

DATE

10/00; 11/03; 04/07

PAGE

4 OF 4

NUMBER

460

NEONATAL GUIDELINES
2.13 Electrolytes in parenteral solutions are determined according to the following: 2.13.1 Physician orders desired solution (e.g. D10W, D5W) and the dose of electrolyte additives in mmol/24h AND mmol/kg/24h. If the infusion rate of the electrolyte solution is decreased to 25% of the original rate due to the adjustment of other parenteral fluids the electrolyte solution is re-mixed or adjustments made in the concentration of other parenteral solutions. If the patient is receiving TPN, the pharmacist will discuss the necessary interventions with the prescribing physician. If an ordered change in TFI will result in a 25% or greater change in electrolyte dosage or infusion rate for an existing solution, the electrolyte solution will be re-mixed prior to implementing the new TFI.

2.13.2

2.12.3

3.0

CLINICAL RESOURCES 3.1 3.2 3.3 3.4 3.5 3.6 Colleen McKenty, Clinical Pharmacist, NICU Dr. Ruben Alvaro, Neonatologist, NICU Dr. Molly Seshia, Section Head, Neonatology Doris Sawatzky-Dickson, Clinical Nurse Specialist, NICU Karen Bodnaryk, Nurse Educator, NICU Dr. John Baier, Assistant Medical Director, NICU

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REFERENCES
4.1 4.2 4.3 4.4 4.5 Fann, B.D. (1998). Fluid and electrolyte balance in the pediatric patient. Journal of Intravenous Nursing, 21(3), 153-159. Hartnoll, G. (2003). Basic principles and practical steps in the management of fluid balance in the newborn. Seminars In Neonatology, 8(4), 307-13. Hewitt-Taylor, J. (1999). Children in intensive care: Physiological considerations. Nursing in Critical Care, 4(1), 40-45. Modi, N. (2004). Management of fluid balance in the very immature neonate. Archives of Diseases in Childhood, 89, F108-F111. Shah, P.S., Kalyn, A., Satodia, P., Dunn, M.S., Parvez, B., Daneman, A., Salem, S., Glanc, P., Ohlsson, A. & Shah, V. (2007). A randomized, controlled trial of heparin versus placebo infusion to prolong the usability of peripherally placed percutaneous central venous catheters (PCVCs) in neonates: The HIP (Heparin Infusion for PCVC) Study. Pediatrics, 119,1, e284-e291. Willock, J. & Jewkes, F. (2000). Making sense of fluid balance in children. Paediatric Nursing, 12(7), 37-43.

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