Question of the Week

Question :
Posted On : 13 Sep 2020
Infant of diab mother with hypoglycemia 27 mg with distress, lethargy. One day old. 4.750 kg.
1-What is maximum fluid can be given and maximum concentra
2-If we are giving a higher concentr and baby started feeding when and how to stop fluid if he is feeding by ngt 30 ml, 2h, and rbs for 3 reading above 50.
3-When we give glucagon. When push therapy to be given and what is the amount?
Expert Answer :
As is obvious in this case, these babies tend to be large for gestational age and are overloaded with fluid at birth. They also tend to have hypertrophic cardiomyopathy and relative surfactant deficiency. Hence a daily total intake of 60-70 ml, kg, day in the first 1-2 days is appropriate so as not to overload the cardiovascular system. These babies usually require an umbilical venous catheter placement through which higher Glucose concentrations {15-20 percent} can be administered if needed. The aim is to adjust the IV Glucose concentrations to achieve a Glucose infusion rate {GIR} of 6-8 mg, kg, min which is usually adequate in most babies to maintain the Glucose levels in the safe range {More than 40 - 50 mg, dL} on day 1 or 2. The GIR is more important than the concentration of Glucose in the fluid and may be increased as required. The calculation method of GIR is mentioned in most neonatal handbooks.
Feeding is to be restricted in rare cases and only if the baby requires very high GIR which necessitates higher fluid volumes which would add up to the oral intake and cause fluid overload. Once a reasonable Glucose control is achieved {as in this baby}with normal GIR rates{4 - 6}, and the baby can tolerate oral feeds well, the IV fluid rate can be tapered down gradually over 24 - 36 hours guided by the serial Glucose monitoring.
Total daily intake is increased in intervals of 10 - 20 ml, kg, day from the 2nd or 3rd day to reach ~ 100 - 120 ml, kg, day by day 4 - 5 or full demand feeding by the baby.
This regime may not be effective in rare cases such as those with Persistent Hyperinsulinemic Hypoglycemia of infancy {PHHI} in which a more gradual tapering of GIR is necessary.
Glucagon IV or IM is indicated in severe or refractory cases of hypoglycemia as an adjunct to routine therapy. It can be used as an emergency and temporary measure if the administration of higher Glucose concentrations is not immediately possible.
A bolus or push therapy is usually indicated in cases of hypoglycemic emergency {symptomatic cases with seizures or coma} when the blood Glucose level is extremely low {not defined}. But the bolus dose should be quickly followed up with continuous Glucose infusion else there will be severe rebound hypoglycemia soon thereafter.
Answer Discussion :
Kur Champion
we can start with 20cc/kg 10% hypertonic and can be repeated after every 2 hours
3 years ago
Ebtihal Khalid
1- we start with 20cc/kg 10% hypertonic and can repeat after 2 hours if no response
3 years ago

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