Including ALL fluids in total allowance?

[wensday, MSN, RN, APN, NP]

I have recently started work at a large respectable NICU and discovered they have changed thier policy of calculating fluids. Basically (I presume this is the same worldwide) you do 75-180ml/kg/day dependant on age and condition etc and then work out thier intake from there...so if it was an infant at 3kg it would be something like 180 x 3 = 540 540 / 24 = 22.5ml/hr and you could then work out how much IV/enteral etc to give as total daily requirement....am I making any sense?!!

Anyway, this unit has recently started ONLY including enteral fluid, TPN or glucose or whatever and insulin in the total intake- ALL OTHER FLUIDS ARE EXTRA TO DAILY FLUID REQUIREMENT.

So, the other day I had a 23weeker on dopamine, dobutamine, morphine solution (continuous), hepinarised nacl to keep a line open, TPN, .5ml EBM 2hourly, um...insulin, and at least two other things...i forget! Also three or four different IV antibiotics and loads of other meds. That is a lot to pump into a kid less than a kilogram.....

So anyway this unit has had a lot of IVHs recently. A lot. Including my 23weeker who sadly died.

Do you reckon it's linked?

(See there was a pont to my story!)

[BittyBabyGrower, MSN, RN]

I'm not really getting what you are saying...in our unit, we count all fluids except antibiotics.

For example...we want 150ml/kg/day on a 1kg baby. Our dopa is running at 0.3ml/hr, Dobut at 0.3ml/hr, insulin at .03ml/hr, art line at 0.5ml/hr, MSO4 at .2ml/hr, and enteral feeds at 0.5ml/hr and TPN at 4.4 ml/hr. Is this what you mean?

As for the IVH's, you have to look at the population, most 23 weekers will have a bleed. Also, Dop and Dobut run a risk of IVH, as does the PDA, etc. The overload would most likely lead to the open duct and then the CO2 will go up and the pH will go down, which can lead to a bleed. Also...we don't feed with lines in as the rate of NEC in the little ones increase and again..sepsis=low pH and risk of bleed. If our kids have a central line, we can have pharmacy make some of the antibiotics more concentrate, and many are compatible with TPN so we don't flush, we just let the TPN run it in. Also, if the kid is having high glucoses or K's, hence the need for insulin, that can also cause bleeds. So, is it related, maybe distantly so.

I hope I made sense LOL

[wensday, MSN, RN, APN, NP]

Um ok, well they only count the 'feeding fluids' as the total amount. So my baby was getting all the fluids that aren't TPN/insulin or enteral as extra to requirements. So using your example, the kid would be on the same enteral and insulin but the TPN would be at 5.72ml/kg and all the rest would run at your rates but the kid would be getting all that fluid as extra to hs daily requirement....I can't think of a way to describe this otherwise!

I know littlens bleed but since they changes the policy they are having a LOT of deaths and it isn't just the littlens.

[BittyBabyGrower, MSN, RN]

Ah gotcha...we used to do that about 15 years ago, then we started counting everything. Do they have a rationale for this way...it seems they are going backwards to me. I'd be interested to see what other places are doing!

[dawngloves, BSN, RN]

Hmmm... That's how we do it. We figure in all meds. But if Dopa is to titrate, we don't figure in that.We also don't figure in blood products. If fluid overload is a concern we give Lasix after a transfusion. We concentrate meds as much a possible also, (ie Dopa 4x concentrate for micros). It would look somthing like:

Fluid requirement 90ml/kg/day

Weight 800 80x.8/ 24 = 3ml/hr

Meds (abx, caffeine) .1

KVO fo UA/UV lines .5x2=1

Lipids .18

So TPN would run at the remainder, 1.72

Anything else, PRBCs, titrated Dopa or MSo4, would not be counted.

I haven't noticed an inordinate amount of IVHs.

[sparkyRN]

One issue I have with calculating fluids, is the difficulty in keeping up with the extra fluid received when lines are flushed. We use 0.6cc 1/4ns barrier with most of our meds plus either 0.5cc when flushing the UAC for a gas or 2cc if we're drawing any lab that includes a glucose. (Our UAC will be our maintenace IV if there is no UVC, which happens more often than not.) Granted, blood is being removed to decrease the circulating volume, but it's not an even exchange.

[BittyBabyGrower, MSN, RN]

With many of our meds we don't flush as they are compatible with most IV fluids, but we limit them to 0.3ml before and after. We also have a VIA system that we use on the very small or sicker kids...it draws the blood up from the UAC to a sensor, computes the ABG, lytes and glucose, puts the blood back and flushes with 0.4ml 1/2 hep'd NS.

We just went to standardized Dopa/Dobut mixtures (I thought all NICU's were going to this as it was mandated by JCH) and no longer can concentrate them. That wastes a lot of our fluid allowance.

When we use the UAC as a main line, we draw 2ml's blood back as "waste", take our sample, give the 2ml's back and then flush with 0.5ml's.

We don't count blood products and use Lasix as needed.

[wensday, MSN, RN, APN, NP]

We were iscussing flushing a broviac line the other day because it takes a lot of fluid.

[prmenrs, RN]

If they're not gonna count drip fluids, they need to be as concentrated as possible and practical. We did count them. You can figure it both ways to get an idea of the difference--might make it more tangible. I think they should NOT count them, but, unfortunately, I wasn't consultated. lol.