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- Seok Joo Han
- Department of Surgery
- Yonsei University College of Medicine
- Seoul, Korea
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- Patient evaluation
- Development and initiation of an initial fluid plan
- Feedback and adjustment of the plan as the result of monitoring
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- Diffusing of water molecules from the superficial capillary to the
surface of skin: keratinization
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- Prediuretic phase(1st day of life)
- urine output is extremely low (< 1 ml/Kg/hr)
- fluid overload may occur at mistaken interpretation
- Diuretic phase(2nd-3rd day of life)
- diuresis(>7.0 ml/Kg) and natriuresis
- Postdiuretic phase(4th-5th day of life)
- urine output and sodium excretion vary appropriately in response to
fluid and electrolyte intake.
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- The percentage of unabsorbed Na in renal tubules
- Indicating of renal tubular function
- Almost all sodium(>99%) is absorbed from renal tubules
- FeNa in term < 1%
- FeNa in prematures : 3-9%
- If elevated BUN/Cr, low volume of isotonic urine,
- and
- FeNa in term infant>2-3% à<=
font
face=3D"Times New Roman"> ATN
FeNa in premature>9% à ATN
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- A 1-kg premature infant, during the first 8 hours postoperatively, =
has 0.3
ml/Kg/hour of urine output. Specific gravity is 1.025. Previous init=
ial
volume was 5 ml/kg/hour. Serum BUN has increased from 4 mg/dl to 8
mg/dl; hematocrit value has increased from 35 to 37%, without
transfusion.
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- Possible Status: hypovolemia
- Adjustments:
- The treatment is to increase the hourly volume to 7 ml/kg/hours for =
the
next 4 hours
- Monitor the subsequent urine out put and concentration
- Reassess the fluid sta=
tus
after 4 hours
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- A 3-kg newborn with CDH during the first 8 hours postoperatively ha=
s a 0.2
ml/kg/hour of urine out put, with a urine osmolarity of 360 mOsm/l. =
The
previous initial volume was 120 ml/kg/day (15 ml/h). The serum
osmolarity value has decreased from 300 mOsm/l preoperatively to 278
mOsm/l; BUN, from 12 mg/dl to 8 mg/dl.
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- Possible Status
- Inappropriate antidiuretic hormone response
- Adjustments:
- Reduce in fluid volume from 120 ml/kg/day to 90 ml/kg/day for next 4=
to
8 hours.
- Repeat urine and serum measurement will allow the further adjustment=
of
fluid administration
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- A 3-kg baby, 24 hours following operative closure of gastroschisis,=
had
an average urine output of 3 ml/kg/hour for the past 4 hour. During =
that
period, the infant received fluids at a rate of 180 ml/kg/day. The
specific gravity of the urine has decreased to 1.006; serum BUN is 4
mg/dl; hematocrit value is 30%, down from 35% preoperatively. The to=
tal
serum protein concentration is 4 mg/dl, down from 4.5 mg/dl.
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- Possible Status
- Overhydrated
- Adjustments:
- Decrease the fluid to 3 ml/kg/hour for the next 4 hours
- Reassess urine output and concentration.
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- A 5-kg infant with severe sepsis secondary to Hirschsprung's
enterocolitis has had a urine output of 0.1 ml/kg/hour for the past 8
hours. The specific gravity is 1.012; serum sodium, 150; BUN, 25 mg/=
dl;
creatinine, 1.5 mg/dl; urine sodium, 130; and urine creatinine, 20
mg/dl.
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- FE Na=3D(UNa/PNa) x (PCr/UCr=
sub>)
x 100
- &nbs=
p;
=3D(130/150) x (1.5/20) x 100
- =3D 0.87 x 0.075 x 100
- =3D 6.5 % (normal =3D 2 to 3 %)
- Possible Status
- Acute Renal Failure (ATN)
- Adjustments:
- Restrict fluid to insensible losses plus measured loss for the next 4
hours
- Reassess the plan using both urine and serum studies.
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