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REVIEW ARTICLE
Keywords
neonate; fluids; salt solutions; colloids;
blood transfusion; NICU
Correspondence
Isabeau A. Walker, Department of
Anaesthesia, Great Ormond Street Hospital
NHS Foundation Trust, Great Ormond
Street, London WC1N 3JH, UK
Email: isabeau.walker@gosh.nhs.uk
Section Editor: Andy Wolf
Accepted 12 November 2013
doi:10.1111/pan.12326
Summary
The physiology of the neonate is ideally suited to the transition to extrauterine life followed by a period of rapid growth and development. Intravenous
fluids and electrolytes should be prescribed with care in the neonate. Sodium
and water requirements in the first few days of life are low and should be
increased after the postnatal diuresis. Expansion of the extracellular fluid volume prior to the postnatal diuresis is associated with poor outcomes, particularly in preterm infants. Newborn infants are prone to hypoglycemia and
require a source of intravenous glucose if enteral feeds are withheld. Anemia
is common, and untreated is associated with poor outcomes. Liberal versus
restrictive transfusion practices are controversial, but liberal transfusion
practices (accompanied by measures to minimize donor exposure) may be
associated with improved long-term outcomes. Intravenous crystalloids are
as effective as albumin to treat hypotension, and semi-synthetic colloids cannot be recommended at this time. Inotropes should be used to treat hypotension unresponsive to intravenous fluid, ideally guided by assessment of
perfusion rather than blood pressure alone. Noninvasive methods of assessing cardiac output have been validated in neonates. More studies are required
to guide fluid management in neonates, particularly in those with sepsis or
undergoing surgery. A balanced salt solution such as Hartmanns or Plasmalyte should be used to replace losses during surgery (and blood or coagulation
factors as indicated). Excessive fluid administration during surgery should be
avoided.
Introduction
In the neonate, fluid homeostasis is determined by the
physiological demands of transition to extrauterine life
and the period of rapid growth and development in the
first few weeks and months after birth. Prematurity
imposes additional challenges due to incomplete organ
development. For the anesthetist, administration of
intravenous fluids to maintain cardiovascular stability is
one of the most basic interventions in pediatric anesthesia, yet practical evidence-based guidelines concerning
intravenous fluid management are surprisingly difficult
to find. Much of the literature regarding fluid homeostasis in neonates relates to neonatal intensive care (in particular management of preterm neonates), where it has
been shown that excessive intravenous fluid is harmful,
2013 John Wiley & Sons Ltd
Pediatric Anesthesia 24 (2014) 4959
50
Body
weight (BW) (g)
Total body
water (%BW)
ECF volume
(%BW)
2327
2832
3640
5001000
10002000
>2500
8590
8285
7176
6070
5060
~40
Neonates are susceptible to disorders of sodium balance, and both sodium and water content in intravenous
fluids need to be considered carefully. Aldosterone secretion is slow to be reduced in the face of a sodium load,
for instance from isotonic fluid boluses, intravenous
flushes, and drugs, and may result in hypernatremia or
sodium retention with edema formation. It is recommended that neonates are given sodium-free fluids until
after the postnatal diuresis to allow for contraction of
the ECF volume (12,13), but inadequate sodium intake
thereafter will result in hyponatremia. This is particularly important in preterm neonates as the RAAS is
less active, and they have a limited ability to retain
sodium in the distal renal tubule. Inadequate sodium
intake is associated with severe hyponatremia and poor
long-term neurological outcomes in preterm neonates
(16).
Insensible water loss in neonates
In adults, insensible water loss (IWL) consists mostly
of water lost via evaporation through the skin (twothirds) or respiratory tract (one-third). In neonates,
IWL from the skin varies with gestational age; the
more preterm the infant, the greater the transepidermal
water loss as there is a higher body surface area to
weight ratio, and the skin in the most preterm neonates
is thin and fragile and poorly keratinized. Use of a
radiant warmer or phototherapy significantly increases
IWL and can have a significant affect on fluid balance.
In extreme preterm infants, IWL losses may exceed
renal water losses (15). Evaporation of water from the
skin is associated with cooling due to the effect of the
latent heat of evaporation. Difficulty in keeping a baby
warm may be an indication of excessive IWL. IWL
may be reduced by nursing preterm infants <2 weeks of
age in a heated humidified incubator (>80% humidity),
but if the baby is taken out of the incubator (for
instance for surgery) or if the incubator is left open for
procedures, this protection will be lost. Insensible water
loss decreases as preterm neonates mature, and ambient
humidity may be gradually decreased with time. The
incidence of hypernatremic dehydration and temperature instability in preterm infants are good indicators
of the quality of nursing care in a neonatal intensive
care unit.
Humidification reduces IWL from the lungs in ventilated babies, and humidification is also required for
babies receiving nasal CPAP or nasal high flow
therapy. Postextubation, respiratory IWL may be high
if a neonate receives unhumidified oxygen via nasal
cannulae.
52
Nutritional requirements
Fluid requirements cannot be considered in isolation
from nutritional requirements, particularly the requirements for glucose, although a detailed consideration is
beyond the remit of this article. Blood glucose falls
immediately after birth, but rises in the first few hours in
response to endogenous glucose production or feeding.
Neonates metabolize ketones as well as glucose as an
important energy substrate in the brain, so are relatively
protected from damage due to hypoglycemia. However,
prolonged hypoglycemia below 2.6 mmoll1 is associated with abnormal neurological outcomes. Preterm
neonates are at risk of hypoglycemia if enteral feeding is
delayed (for example, to reduce the risk of NEC), and
they have limited glycogen stores. Intravenous glucose
should be provided to babies at risk of hypoglycemia at
a starting rate of 57 mgkg1min1 (10% dextrose
70100 mlkg1day1), and blood glucose should be
monitored (15).
Blood transfusion
Anemia is common in neonates in the NICU, partly due
to the transition from synthesis of fetal hemoglobin to
adult hemoglobin A that starts at birth, limited responsiveness to erythropoietin in the neonate, and rapid
growth. Anemia is also related to timing of clamping of
the umbilical cord at birth, iatrogenic anemia from
repeated blood samples in the NICU, sepsis, and surgical interventions (17,18).
Untreated anemia is associated with apnea, poor
weight gain, and poor neurodevelopmental outcomes.
It has also been suggested that prior blood transfusion
may be a risk factor for NEC, particularly in extreme
preterm neonates, although the precise mechanism is
not clear. Suggestions include alterations in gut perfusion associated with feeding in neonates with hemodynamically significant PDA, the severity of preexisting
anemia, or immunological mechanisms associated with
the transfusion of red cells without leukocyte depletion (19,20). Interestingly, neonates are also disproportionately represented in the UK Serious Hazards of
Blood Transfusion reporting system, primarily related
to misidentification (lack of wrist bands), and over
transfusion (18). As neonates are such frequent recipients of blood transfusions, questions arise as to what
trigger for transfusion should be used, what should be
the target hemoglobin, and how to minimize donor
exposure. Hemostasis in neonates is discussed elsewhere in this journal and will not be considered here
(21).
Suggested
hemoglobin (gl1)
120
<120
<110
<100
>90
75
contour analysis, echocardiography, and transesophageal Doppler (TED) (52). The National Institute for
Health and Care Excellence medical technologies guidance supported the use of the CardioQ-ODM esophageal Doppler monitor in adults undergoing major or
high-risk surgery, or where invasive monitoring would
be considered. Use of the TED was associated with
reduction in postoperative complications, the need for
central venous access, and the length of stay compared
with conventional clinical assessment (53). TED has
been shown to provide an accurate assessment of cardiac output in children of all ages when compared with
thermodilution and can track changes in cardiac output
in response to fluid loading or changes in inotropes (54).
TED has also been used in neonates and infants 2.5
5 kg undergoing surgery and to identify fluid responsiveness more reliably than clinician assessment; the
authors suggested that the use of the TED may guide
appropriate fluid management during surgery and
would help avoid excessive fluid boluses in neonates
where there is no increase in cardiac output in response
to a fluid challenge (55).
Laboratory assessment
Term/LBW
VLBW/ELBW
Day 01
Day 2
Day 3
Day 4
Day 5
5060
7080
100120
120150
150180
8090
120
150
180
180
LBW, low birth weight <2.5 kg; VLBW, very low birth weight
<1.5 kg; ELBW, extremely low birth weight <1 kg.
2013 John Wiley & Sons Ltd
Pediatric Anesthesia 24 (2014) 4959
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